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<o08 

8 






LIBRARY 

Walter E. Fernald 
State School 




Waverley, Massachusetts 
No. 






A COLLECTION 
OF ORTHOPEDIC PAPERS 

BOOK THREE 

Mobilization of Ankylosed Joints 

Recurrent Dislocation of the Patella 

•. 3. Transplantation of the Entire Fibula in Cases of 
Loss of Tibia from Osteomyelitis 

t 4. Ankylosis : Treatment by Arthroplasty 

M. Intrinsic Splint Traction 

I 6. Astragalectomy (The Whitman Operation) in 
Paralytic Deformities of the Foot 

\ 7. Recurrent Dislocation of the Shoulder 

% 8. Injuries to the Musculospiral Nerve 

| 9. Mobilization of the Elbow by Free Fascia Trans* 
plantation with Report of Thirty-One Cases 



t 10. Backache 



\ 



1925 



/jfeyfe^ /;/>**> ? 



No <%££:.. 

This book is'the property of the 

Massachusetts 
School for the Feeble-Minded. 

WAVERLEY, MASS 




Reprint from 
SURGERY, GYNECOLOGY AND OBSTETRICS 

September. 1923, pages 255-309 



MOBILIZATION OF ANKYLOSED JOINTS 1 

By-'W. RUSSELL MacAUSLAND, M.D., Boston 
Surgeon-in-Chief, Orthopedic Department, Carney Hospital 

Introduction that various methods may be presented with 

MUCH progress has been made in the the assurance that they will continue to be 

surgery of bones and joints in recent more or less standard in future work. Today 

years, due largely to the extraor- Payr, Putti, and Baer, persisting in the face 

dinary perfection of technical methods and of adversity, have opened this limited field of 

the persistent efforts of a few able leaders, surgery so that carefully trained operators 

Probably no section of this field has occupied with highly developed technical skill can now 

so much interest and effort as the surgery of present results which show only a small per- 

stiff joints. centage of failures. The risk to life is very 

The best teaching, until very recent years, low and the margin of good results reasonably 

dealt almost entirely with the proper position certain. 
in which a joint should be allowed to ankylose 

so as to permit the best function. The shoul- arthroplasty not an excision 

der stiff in abduction is certainly much better Arthroplasty, or the operation of mobilizing 

functionally than the shoulder stiff at the side ankylosed joints, is not an excision. Murphy 

of the body; the knee stiff in almost full exten- has well said: "Arthroplasty to be functional 

sion is undoubtedly far less of a disability than must be stable, and excision of joints results 

the knee fixed in marked flexion. And yet, always in flail joints. " A flail joint cannot be 

with the gradual development of surgical considered a proper result from a plastic 

technique, certain pioneers in joint surgery operation. Excision has no place in the sur- 

have tried to increase function by different gery of weight-bearing joints, save to ob- 

methods. tain ankylosis, nor would it be used in non- 

Although the mobilization of ankylosed weight-bearing joints if it were not that flail 

joints was at first, and is even now, attempted joints may be stabilized by means of light 

by only a few surgeons, several good results apparatus. 

arising in a sea of failures led the pioneers on- Those who attempt to mobilize ankylosed 

ward to develop this new field of surgery, joints must approach the work well trained, 

Foremost among them is the late John B. must show great technical skill, and, above 

Murphy, of Chicago, to whom we pay a all, must exercise judgment in their selection 

tribute of admiration for his constructive of cases, if they would qualify for this work, 

efforts founded on a vast accumulation of I present the subject of arthroplasty to you, 

clinical and scientific material. The results of therefore, in order to stress these important 

operations have been sufficiently definite so points: 

1 Presented before the International Congress of Surgery, London, July iS, 1523. 



SURGERY, GYNECOLOGY AND OBSTETRICS 



i. That excision of a joint does not con- 
stitute an arthroplasty; 

2. That highly developed technical skill is 
absolutely necessary; 

3. That the judgment in the selection of 
cases is very difficult. 

Types or Ankylosis — Infectious, Non- 
Tuberculous, Traumatic 

Ankylosis is the result of an infectious 
process or traumatism. The latter is usually 
a fracture dislocation with wide separation of 
fragments, followed by excessive callus. The 
ankylosis in these traumatic cases is usually a 
firm fibrous formation, although occasionally 
a true bony ankylosis may result. 

The infectious process may be either acute 
or chronic. In the former case the causative 
agent is usually the streptococcus, the pneu- 
mococcus, or the gonococcus. In these in- 
fections the onset is sudden, and the course 
severe, ending usually in a bony ankylosis. 
We may, on the other hand, have a slow, in- 
sidious, polyarthritic process. The focus of 
infection is situated elsewhere and the joint 
condition is caused by the hasmotogenous de- 
posits in the joint, either of attenuated bacte- 
ria or of toxins. The primary focus is often 
difficult to locate. The ankylosis results from 
adhesions both within and without the joint, 
and is, at least at first, fibrous in character. 

Murphy (1 20, b) believed every type of non- 
traumatic joint inflammation to be the metas- 
tatic manifestation of primary infection in 
some other part of the body. Sometimes long 
periods elapse between the primary infection 
and the secondary arthri tides. Gonococci 
metastases usually occur in 18 to 20 days, 
staphylococci in 10 to 14 days, and streptococ- 
ci and colon bacilli in 8 to 10 days. These 
metastatic joint infections are initiated with 
a chill, and are not rheumatic in character. 

The synovia is first involved; the serous 
surface of the membrane is destroyed in large 
and small areas. Up to a certain extent it may 
be repaired. In extreme erosions subserous 
tissues bridge over the spaces between the 
serous erosions, and adhesions result. The 
gonococcus, pneumococcus, and streptococcus 
may produce this condition. Pathology shows 
thick, porky infiltrations of the synovial mem- 



brane, oedema of the subserous surfaces, and 
injection of the surface toward the joint. The 
cartilage is not affected at an early date. In 
repair, the proliferated epitheloid cells become 
obliterated. 

Causes and Extent of Ankylosis in 
Relation to Mobilization 

It is important to emphasize the necessity 
of determining the cause of ankylosis, for it 
makes a great difference whether the anky- 
losed joint is the result of fracture or of dis- 
ease, or whether it is congenital. 

Infections, either acute or chronic, do not 
constitute a contra-indication to the opera- 
tion, provided that the process has not been 
tuberculous or is not active. It is well to point 
out that many joints, apparently firmly an- 
kylosed even by a bony bridge, may retain 
active infectious agents for a year or even two 
years. A tuberculous joint, even when anky- 
losed firmly, may retain small walled-off foci 
throughout life, and, therefore, except in cases 
of great rarity, should be considered a direct 
contra-indication to any mobilizing. 

Certain infections cause great destruction 
of bone and injury to the soft structures of the 
joint. Where such destruction is extensive, or 
where there is marked scarring of the tissues, 
a difficult operation may be expected. 

Occasionally deformity of such extent is 
present as to warrant the correction of the 
deformity before arthroplasty is attempted. 
The hip, for instance, ankylosed in marked 
flexion and adduction, will present a very diffi- 
cult operative problem, unless the deformity 
is first corrected by a preliminary procedure. 
Marked flexion of the knee, although not so 
important, may also necessitate a preliminary 
intervention. 

In general, I have found bony ankylosis 
easier to deal with than partial or the so-called 
fibrous type. 

Indications and Contra-Indications 
for Arthroplasty 

Any ankylosed joint might be considered for 
arthroplastic procedure, but there are definite 
limitations, and therefore we come to have 
certain fundamental indications for arthro- 
plasty. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 3 

Major joints. First, two stiff hips will in- Rodgers (155), of New York, modified this 

dicate arthroplasty on one hip, or possibly method in 1830 by removing a disc of bone 

both. Second, two stiff elbows will present from between the trochanters. He obtained a 

the same indication. Third, two stiff knees more satisfactory result. Berard (13), Es- 

will present a definite indication for an march and Rizzoli, both reported by Murphy 

arthroplasty on one side, at least. Fourth, (120, g), and Mcllhenney (114) used similar 

combinations of hips and knees in the same methods for treatment of the jaw. 

individual, a condition not infrequently seen In 1880, Wolff (197) recommended a method 

in multiple arthritis, is a very definite indica- which he called arthrolysis, which consisted of 

tion for attempting to mobilize one or more chiseling through and dividing all fibrous or 

joints. The surgeon considers in all of the bony adhesions, without resection of the 

above indications the anatomical and occupa- articular extremities that had been restored 

tional status of the patient. to their normal position. Wolff claims favor- 

Minor joints. Among the lesser joints which able results in nine cases, four of ankylosis of 

may be considered properly a subject for in- the fibrous type and five of the bony type, 

tervention are: first, stiff shoulders; second, It is probable that he did not treat a true bony 

stiff fingers; third, stiff wrist (a very rare sub- ankylosis. 

ject for arthroplasty) ; fourth, the jaw, which Kocher (103) suggested dislocating the 

demands arthroplasty. joint for a short period after arthrolysis. No 

In general it may be said that definite in- success is reported, 
dications naturally rest with the judgment of Actual resection has a few advocates. Good 
the surgeon, but must depend to a large degree functional results have been reported in a 
upon the patient. One stiff elbow, for in- proportion of cases of ankylosis of the jaw, 
stance, in some individuals is a very slight elbow, and hip. Koenig (104) recommended 
disability; in others, it is of supreme impor- resection in wide luxation. Textor (178) in 
tance. It is necessary, therefore, that each 1843 reported a case of ankylosis of the elbow 
case be considered upon its merits and not in which there was full range of motion 6 
upon the mere desire of a patient to be able years later. Ferguson (63) secured a weight- 
to move a joint. There should be considered bearing limb by resection of the knee. Daut- 
constantly the question of whether the de- relepont (45), Czerny (42), and others ob- 
formity may be actually the principal source served that a new joint cavity with synovial 
of disability, and whether, as has been men- membrane and articular cartilage formed 3 
tioned before, correction of deformity may years after resection. Sayre (161) and Defon- 
not give sufficient relief to the patient. taine (47) tried to fit bony ends after the 

fashion of an articulation. They obtained 

Methods of Treatment— General Sur- stability, but adhesions formed again. Dartig- 

vey Prior to Arthroplasty nes ^ described a trochleariform osteotomy; 

Many means have been used to gain mobil- he resected the joint surfaces with preserva- 

ity in ankylosed joints. Previous to i860, tion of their form. The result was ankylosis 

brisement force was the general method of again. Cavazzani (29) liked to spare the bone 

treatment. It is still in use, and in properly and soft parts for the preservation of the 

selected cases the results are good. physiological function. He emphasized a 

J. Rhea Barton (n), of Philadelphia, in transverse incision. 
1826, first attempted pseudoarthrosis in the Painter (133) recommended excision, for in 
case of ankylosis of the hip joint. The opera- arthroplasty he feared the extrusion of the 
tion consisted of an osteotomy through the interposed material, or infection. Resection 
femur above the trochanter and the attempt cannot, however, increase function in a weight- 
to prevent bony union by movement. The bearing joint, as the one essential — stability — 
patient lived 6 years with a good weight- is lacking, and, while resection in the upper 
bearing leg and some motion in all direc- extremity is practised and is as good as a poor 
tions. arthroplasty, it does not measure up with a 



4 SURGERY, GYNECOLOGY AND OBSTETRICS 

good arthroplasty either in surgical technique passive were secured. Movement was im- 

or in functional result. proving at the time of the report. 

Very little has yet been done in the trans- Goebell (72) implanted a toe joint into a 

plantation of half or whole joints. Lexer's finger resected for severe arthritis deformans, 

(no) first case was to implant in a stiff elbow A good movable finger resulted, and the 

of gonorrhceal origin the patellar surface of the patient, a violinist, resumed her profession, 

femur. The result was fibrous ankylosis. His G. T. Vaughan (185), of Washington, was 

next step was to use a transplant of the entire unsuccessful in replacing a knee taken from 

knee joint. The knee joint was hxed in acute the cadaver. The graft became the site of 

flexion in bony ankylosis, resulting from suppuration. 

articular suppuration after purulent osteo- Kuettner (106) reported two cases of im- 
myelitis of the femur. He made an anterior plantation of femoral neck and head, using 
flap incision, the soft parts remaining in con- the cadaver as the source of material. One 
tact with the flap. All lateral and posterior patient walked without a cane and had con- 
coverings were detached. A new joint, ob- siderable motion. An autopsy at death from 
tained from a limb amputated simultaneously vertebral metastasis, 1 year and 1 month after 
for senile gangrene (without phlegmon), was operation, showed the joint fixed to the 
fitted in. In this case he neglected to place femoral shaft by a narrow ring of bony callus, 
tissue beneath the patella, thus necessitating The whole graft was covered by a membrane 
a second interference. Fixation by plaster similar to periosteum. The second case re- 
cast from toes beyond the iliac crest followed, mained cured 3 years and 2 months. Local 
Three months later the epiphyses were in firm recurrence necessitated disarticulation of the 
union, the semilunar cartilage preserved, and hip. 

the articular cartilage was smooth. A small Deutschlander (52) tried transplanting in a 

spicule of bone was later excised and analyzed, child of thirteen a graft containing the joint 

The transplanted portion had become a part extremities of the femur and tibia with the 

of the new organism. greatest part of the joint capsule, menisci, and 

The second case Lexer reported was a ligamentous apparatus. Ten months after the 

transplantation for bony ankylosis of a tuber- operation, the transplant was luxated and re- 

culous knee joint. The entire joint was again moved. 

taken from a freshly amputated limb. In both Oehlecker (126), in 1922, reported the out- 
cases the extremity was somewhat shorter, come, after 6 years, of eight cases in which an 
The knee joint was in normal extension, entire joint was transplanted into a finger. In 
Lateral motion was present in the second case, four cases the joint was taken from the patient 
Both patients could bear their weight well himself and in others from another person, 
when walking or standing. Lexer then aimed The results in the autoplastic cases were more 
to obtain function by muscle plastic elonga- successful, 
tion of the efficient non-atrophic muscles. Work with whole and half joints has been 

Herzberg (83) reported four cases in which done by Sievers (169), Petraschewskaja (137), 

transplantation of joints was done after re- Katzenstein (97), and Buchmann (24). 

section. Three of the cases were children. There is much discussion in regard to the 

Eloesser (60) reported a case of implanting regeneration process. Axhausen (8) in 1907 

a cadaveric joint consisting of three inches of proved that periosteum and endosteum of 

tibia, fibula, and astragalus. The attendant implants remained alive. Eloesser (60) be- 

dropped the implant during the operation, lieves regeneration takes place in part from 

which necessitated heating it. Suppuration the elements of the graft itself, 

developed and the foot was amputated. Ex- The cadaver material is easier to obtain 

amination showed the tibia was invaded by than a living graft, but infection must be 

new bone in all stages of formation. In a case avoided. The joint is removed within 12 

of implanting a finger joint from the cadaver, hours after death. The Wassermann test is 

35 degrees active motion and 60 degrees used on the blood and part of the bone marrow 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



is incubated in broth. The joint is implanted 
in Ringer's solution for 24 hours. It is then 
freed of all adherent tissue and muscle. 

In the operation a horseshoe flap is outlined 
and the bone is sawed close to the joint. The 
new joint is inserted by mortising and held in 
place by catgut. Traction is secured by ad- 
hesive plaster strips. A plaster-of-Paris splint 
is then applied. General passive motion is 
instituted in a week. 

This surgical procedure seems at once rad- 
ical and dangerous, and has not been gener- 
ally accepted. Simple arthroplasty, without 
the use of bone transplants and with little use 
of any foreign heterogeneous material, has 
supplanted all such extravagant measures. 
Their interest is chiefly historical. 

Various non-absorbable materials have been 
tried as the interposed material. Carnochan 
(27), of New York, in 1840, inserted a piece of 
wood in an ankylosed jaw. Orlow (130) in 
1901 used gilded aluminum plates in two jaw 
cases. Roser (158), Pupovac (144), Huebscher 
(93), Hoffa (86), and others used magnesium 
plates and silver. Chlumsky (7,7,) tried zinc 
and rubber, but reported no permanent re- 
sults. Later he used absorbable plates of de- 
calcified bone, ivory, and magnesium, but the 
results, on the whole, were not satisfactory. 
Gluck (70) and others inserted ivory pegs. Be- 
sides these materials, celluloid, gutta percha, 
and temporary packings of gauze have been 
used. Foederl (65) in 1903 used animal mem- 
brane or walls of ovarian cysts, but found that 
they caused suppuration, and re-ankylosis 
occurred. 



Rechet (148) covered the ends of the re- 
sected bones in various joints with periosteal 
flaps. 

Hofmann (87, a), in 1906, reported a case in 
which he transplanted periosteal flaps from 
the tibia to the resected ends of the bones of 
the elbow. He obtained full extension and 
flexion to 80 degrees. 

Von Frisch (66) used periosteal grafts from 
the tibia in an elbow ankylosed from gonor- 
rhceal arthritis. Only 25 degrees motion was 
obtained. The author attributed the result 
to lack of after-treatment. 

Greiffenhagen (75) reported three cases in 
which periosteum was used in elbow joints. 

A graft of joint cartilage was first used with 
success by Tuffier (183) in 1901 for a com- 
minuted fracture of the upper end of the 
humerus. Judet (96) doubled the cartilage 
with a layer of bone. 

Mauclaire (112) used cartilage from the 
astragalus to cover the rough ends. Later the 
X-ray showed these fused to the bone. 

Weglowski (189), in 1907, reported a case 
in which he successfully used cartilage from 
the rib in an ankylosed elbow. 

More recently cartilage grafts were used by 
Delageniere (48) after a resection had been 
done. The operation showed no advantage 
over excision, as some instability of the joint 
followed. 

Gluck (70), in 1902, used skin flaps. 

Diel (53) reported the use of reindeer tendon 
and the epiploon of a rabbit in a case of 
femoral-patellar ankylosis. In 10 months the 
patient could walk easily without a cane. 



ARTHROPLASTY 



History 



Foreign substances are no longer used, and 
since 1900, fat, muscle, fascia, or specially pre- 
pared membranes have been inserted in the 
joints. 

The first case of muscle interposition was 
in the jaw, where immobility often interferes 
with life. In i860, Verneuil (186) interposed a 
piece of temporal muscle and fascia between 
the condyle and glenoid after resection. Hel- 
ferich (80) and Oilier (129) developed the 
technique of muscle implantation and gave it 



general notice. In 1893, Helferich exhibited a 
child who had regained motion in an ankylosed 
jaw by use of a flap of temporal muscle. 
Lentz (108), Henle (82), and others repeated 
the operation, using muscle flaps. Both 
coronoid process and condyle of the inferior 
maxillary were removed by Bilczynski (17) 
and Hoffa (86), and a flap of temporal muscle 
inserted. 

In 1895, Mikulicz (118) used a flap from the 
masseter muscle instead of from the temporal. 
Kusnetsoff (107) repeated the operation per- 



6 SURGERY, GYNECOLOGY AND OBSTETRICS 

formed by Hoffa and Bilczynski, using a Kolazek (105) in five experiments on dogs 

masseter flap as the interposed substance, excised a portion of the capsule and inserted 

Rochet (154) and Schmidt (165), after the homo-transplants of peritoneum. They healed 

removal of the entire ramus, interposed a and formed no adhesions, 

masseter flap. Sumita (175) destroyed the joint surfaces of 

Operations on other joints followed those of the knee, hip, and ankle of twenty dogs and 

the jaw. In the treatment of the elbow, Quenu interposed pedicled flaps of muscle, fascia, 

(146), Albarran (2), Nelaton (123), Delbet and tendon. The dogs were observed for 

(50a), Murphy (120), Hoffa (86), and Schanz periods of 21 to 244 days. Fibrous tissue and 

(162) used flaps from a muscle contiguous to small cavities had formed, but the largest 

the joint. Berger (15) in 1903 mobilized a cavity measured only 1.5 centimeters in 

fibrous ankylosis by inserting a flap of the diameter. 

anconeus which he sutured to the brachialis Bolognesi (20), in a long series of experi- 

anticus. Huguier (94b) introduced in the ments, followed the process of formation of 

radio-ulnar joint a layer of the posterior periarticular nearthrosis. He believed that an 

ulna. enarthrosis or a true diarthrosis can be formed 

Muscle flaps were then used by Rochet only when a foreign element is interposed, and 

(154), Nelaton (123), and Hoffa (86) in that the means of covering the cavity had 

ankylosis of the hip, and others used them in origin in the cartilage of the neoformation 

the knee. which covered the free fragments of the 

_, __ fracture. 

Experimental Methods Segale (l6?)) in 1QI ^ in experiments found 

Unfortunately the experimental work in that the joint capsule in a rabbit or dog repro- 

arthroplasties on animals has been relatively duces itself from the surrounding tissues and 

small. forms a new capsule which limits the joint 

Experiments with living tissue have shown cavity and contains synovia. The reproduc- 
that it degenerates or is replaced by a fibrous tion of the joint surroundings is closely con- 
tissue. Small cavities are formed during this nected with the operative technique which 
process. Allison and Brooks (4) found that provides for the preservation of those parts 
the end-results of simple resection of joint which assure a correct joint mechanism, 
surfaces without interposition of a substance Ely (61) experimented on nineteen dogs, 
do not differ materially from cases in which using no interposing material. Bony ankylosis 
the substance was inserted. developed in one case in 432 days. 

Murphy ( 1 20, g) destroyed joint surfaces and Hohmeier and Magnus (90), in a series of 

interposed flaps of fat and fascia. He claimed experiments on dogs, found the end-results 

that the fat undergoes connective-tissue were the same with or without interposing 

changes which facilitate the bursa formation, substances. 

Neff (122) reports only one successful case Beye and Steindler (174) experimented on 
of four arthroplasties on dogs, using free dogs and found no adhesions formed after 
transplants from the rectus aponeurosis, mere scraping of the cartilage covering and 
Three cases were ruined by wound infection, inserting of fascia. Pedunculated muscle 
The successful operation on the knee showed fascia was transformed into a connective- 
new capsule had formed connective tissue tissue pannus adherent to denuded areas of 
between the tibia and femur, and that two bone. There was complete transformation 
bursal sacs had developed. into connective tissue and no traces of original 

Davis (46) in his experiments on a dog muscle fibers existed, 
found, at autopsy, that free fascia in the knee Experiments were then made using non- 
joint was adherent to the end of the femur absorbable materials, but they were discarded, 
and the material was viable. Putti (145, d) also Allison and Brooks (4) found that the 
used free fascia, and found the substance re- chromicized pig's bladder suggested by Baer 
tained normal characteristics. caused reaction in the surrounding tissues, 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 7 

and adhesions formed. They experimented Baer advised chromicized pig's bladder as 

with silver impregnated fascia and found the transplanted medium. It is thin and 

relatively little reaction in the surrounding flexible and conforms accurately to the sur- 

tissues. faces of the modeled bones, and is tenacious 

Phemister and Miller (139) obtained similar enough to withstand disintegration for a pe- 

results in the elbows and knees of dogs, with riod of from 60 to 100 days. 

or without the interposition of free or pedun- The use of Baer's membrane has not become 

culated flaps. The flaps largely broke down, universal on account of numerous failures and 

and the resulting joints were alike in the three sloughing out of membrane, often weeks and 

types of operation. They did not see how any months after the healing of wounds. Allison 

appreciable amount of nutrition can be fur- and Brooks (4) found that with Baer's mem- 

nished by the circulation through the pedicle, brane the reaction of the surrounding tissues 

They believed that the circulation in the sur- was of such intensity that adhesions formed. 

viving portions is through adhesions to the In 1913 they recommended the use of silver 

parts with which they come in contact. impregnated fascia from which there was rela- 

_ , _ tively little reaction. 

Present Clinical Methods In the use of the « free flap >, as the inter . 

The methods in use today, as outlined by posing material, there is an opportunity to 

Murphy (120), Payr (134), Baer (9), Allison obtain the correct size, to determine the 

and Brooks (4), Putti (145), and the writer presence of a bursa, and to secure a good layer 

(in), have in common the exposing of the of fatty tissue. Putti (145) states that fascia 

joint surfaces, modeling of the bone-ends after will live after transplantation; there is, there- 

the conformation of the normal joint, and fore, no need to use pedunculated flaps. He 

the interposition of a substance to obstruct believes that the free fascia grows and is trans- 

effectively bony union. They differ particu- formed into a tissue like the synovia. He covers 

larly in the substance interposed. the epiphysis completely with free aponeurotic 

The two essential features of the Murphy flaps from fascia lata. One difficulty he has 

treatment are the interposition of the pedicled met in the use of these flaps is necrosis of the 

fat and fascia flap and the application of edges, a condition existing even in satisfactory 

traction. Murphy (120) emphasized the in- cases. 

elusion of the fat, as he believed it essential to Putti has been particularly successful in his 

a new joint foundation. It was his belief, too, operations on the knee. I shall treat his 

that the flap was nourished through the technique under the division on the knee 

pedicle. His technique in the different joints joint. 

varied, not in principle, but as necessitated by Payr (134, b) advises the careful extfrpation 
the different joints. It will accordingly be of the capsular tube leading to the nerve- 
treated later under each joint. The writer endings; the removal of the masses of con- 
believes that pedunculated flaps are entirely nective tissue is not enough. Under the infiu- 
unnecessary, and when covered with fat they ence of the rapidly resumed function, there 
interfere with the highest technique. develop in and between the interposed soft 

Baer (9) objects to the interposition of portion (fat or fascia, etc.) at first multiple, 

muscle or fascia for several reasons. He main- and later connected interstitial spaces which 

tains that the structure of the joint is inter- finally form a joint space. A new satisfactory 

fered with when a bulky substance is inserted; capsular tube is formed out of the periarticular 

that too large an excision is required; that, if connective tissue in which other accessory 

too little muscle or fat is interposed, ankylosis ligaments may develop by simple mechanical 

results; that the pain is severe, due to the exercises. The new joint contains a synovial- 

pressure on the nerve-endings ; that the motion like fluid. 

obtained is generally unnatural in character; Payr has obtained the best results with 

and that periarticular tissues are interfered pedunculated flaps and freely transplanted 

with. fat. In all cases Payr has found that the opera- 



8 SURGERY, GYNECOLOGY AND OBSTETRICS 

tion has increased the breadth of excursion of satisfactory, as the joint becomes flail, weak, 

the joint motion. Patients with an ankylosed arid usually requires external support in the 

knee, leaving the hospital with 65 degrees ac- form of a leather armlet with limited elbow- 

tive mobility, showed 90 degrees or more after joint motion. Excision, therefore, is rather 

a year or so. The movement is usually a crude surgical procedure, and the ultimate 

smooth and painless. The X-ray showed the results from its use do not warrant its being 

newly formed joint to be smooth and sharply considered for any condition except tubercu- 

defined; there are no free bodies. From a func- losis of the elbow. 

tional point of view also the new joints are For many years the writer has been working 

satisfactory. He advises being careful in oper- to improve the method of procedure in these 

ating for ankylosis of tuberculous origin. cases, and has found that, with each improve- 

Payr's technique is recommended by Wol- ment in the technique, a definite improvement 

lenberg (196), who, however, warns against in the function of the elbow- joint motion is 

the general use of arthroplasty, as too often obtained, until finally the operation which is 

mobility is purchased at the cost of an un- at present employed, namely, a true arthro- 

stable joint. plasty, has been evolved. 

The writer (1 1 1 , a) first used free fascia in an A good arthroplasty gives a smooth gliding 

ankylosed elbow in 1908. In 19 14 four cases joint, so frequently emphasized by the late 

of free fascia transplants with excellent stable John B . Murphy. The range of motion is 

joints resulting were reported before the excellent, the strength approaches normal, the 

Orthopedic Section of the American Medical stability is normal, and the joint is painless 

Association in Detroit. A series of thirty-one and tends to stand rather severe work without 

cases of elbow arthroplasties was reported in showing arthritic changes. 

192 1. To my mind, therefore, the operation of 

Ritter (reported by Thorn, 179), Behn, re- arthroplasty on the elbow is to be considered 

ported by Harris (79), Kirschner (100), and in a different category from the old operation 

others have also used free flaps. of excision. However, I wish to emphasize 

four important points : first, the necessity for 
elbow ^g p r0 p er selection of the case; second, care- 
Most joints, when stiff, can be placed in a ful preparation for operation; third, strict ad- 
position to function well. The position in herence to the technique of the operation; and, 
which maximum function is obtained in the fourth, proper after-care. No arthroplastic 
elbow is near 90 , and many surgeons ad- method should be attempted until 2 years 
vocate it in preference to a mobilized joint, after an infectious process has been quieted 
But ankylosis of the elbow joint, even at this down, and until at least 1 year after a trau- 
most satisfactory angle, has very objectionable matic ankylosis. These two groups include 
features. fractures, infectious arthritis, and a few 

While function may be present if the elbow neisserian joints, 
joint is ankylosed in flexion, it is never good Ankylosis of tuberculous origin requires 
function, and the arm is always in the way. other treatment, and arthroplasty is indicated 
Usually, too, ankylosis is found in extension of in only the most unusual case, 
about 160 degrees, in which position the arm There have been more arthroplasties on the 
is awkward, although not unsightly. Given, elbow than on any other joints. One of the 
then, an ankylosis of the elbow joint from early cases of arthroplasty using a muscle flap 
any cause except tuberculosis, some type of was reported by Albarran (2). Ankylosis had 
mobilization operation may be considered followed operative reposition. A partial re- 
indicated, section was done by which a good immediate 
Resection, which is performed for the result was obtained, but later ankylosis oc- 
tuberculous joint in adult patients, is the curred again. A third operation was under- 
operation which is usually thought of first, taken, which consisted of a resection of the 
The results from this procedure are very un- olecranon and interposition of a muscle-fascia 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 9 

flap of the triceps. After 2 years there was a below the level of the olecranon. After the 

range of motion from 65 to 115 degrees. bony parts had been remodeled, the fascia was 

Nelaton (123), in a case of ankylosis follow- drawn down and turned into the joint around 

ing neisserian infection, resected an elbow and the inner margin of the olecranon. The 

interposed a flap of the brachialis anticus. proximal portion of the flap covered the 

Two years after the operation, flexion and trochlea, lined the olecranon depression and 

extension were normal, but pronation and the lesser sigmoid cavity, while the distal 

supination were much decreased. Active ex- portion covered the external condyle. Subse- 

tension required the weight of gravity. quent events showed that the flap was not 

In 1903, Quenu (146b) reported an arthro- carried sufficiently high on the anterior surf ace 

plasty of the elbow for an ankylosis following a of the humerus to permit adequate flexion of 

severe trauma of the arm, consisting of a the joint. Five months later, the patient 

fracture of both bones of the forearm and could pass his hand through an arc of 5 inches, 

destruction of the soft parts. After resection Pronation and supination were about one-half 

he interposed a tendon fascia flap. There re- normal. His second case was reported 2 

suited flexion to a right angle and good but months after operation. The hand could be 

incomplete extension. There was good pro- moved through an arc of 3 inches and the 

nation, but difficulty in maintaining an inter- elbow forcibly flexed to an acute angle and 

mediate position. The patient died of pul- extended to 160 degrees. Pronation and 

monary tuberculosis a few months after the supination were approaching normal, 

operation. Hoffa (86), in 1906, reported a series of 

Delbet (50, a) also reported mobilizing, in a arthroplasties, seven of which were on the 

girl of six, an elbow which had become anky- elbow. One, using a magnesium plate, was 

losed in infancy, resulting in complete atrophy unsuccessful, owing to formation of gas in the 

of the arm. At his first operation he resected joint. A fistula resulted which closed only 

the joint without breaking up the ankylosis, when the plate was removed. The operations 

Two months later, after re-ankylosis, he inter- in which fat, fat and fascia, and fascial flaps 

vened again, removing the bony spicules that were used were all successful. In two of them, 

had formed 0.5 centimeter thick, from the ankylosis followed scarlatina; in the others, 

humerus, radius, and ulna. Some fibers of the gonorrhceal infection. 

flexor carpi ulnaris were interposed. Chloro- In 1905, Quenu (146, c) reported a third case 

form mobilization was necessary a month in which there was great atrophy of the mus- 

later, but the final result was good, with cles. He used for a flap the inner part of the 

flexion to a right angle and extension nearly triceps sutured to the anterior ligament, 

complete. Passive movements were begun in 10 days, 

Schanz (162), in 1904, reported a mobiliza- and later electrical treatment was used. As 

tionof a bony ankylosis following rheumatism, active movement was incomplete at the end 

After chiseling through the joint, he enlarged of 2 months, he made a second intervention to 

the sigmoid fossa, removed a piece of the recover a part of the tendon of the triceps, of 

trochlea, and interposed a flap of fat from the which a large portion had been sacrificed. He 

under side of the forearm. Three months after cut the portion interposed close to the bone, 

the operation the arm could be used for He could then ascertain that there was no 

ordinary purposes. adherence between the superior surface of the 

Murphy (120, a) first mobilized the elbow by interposed segment and the inferior cut sur- 
his method in 1904, in a case of ankylosing face of the humerus. The same condition 
arthritis. A pyriform flap of deep fascia was existed on the inferior surface. The tendinous 
dissected from the posterior surface of the segment had left a distinct cavity. The 
triceps. The flap was 4^2 inches long by 2 tendon of the triceps was sectioned and re- 
inches wide at its upper end, and received its inserted on a little fibrous flap previously dis- 
blood supply from a broad pedicle which re- sected on forearm. Patient gained not quite 
mained attached to the muscle and fascia just complete extension, and flexion to right angle. 



io SURGERY, GYNECOLOGY AND OBSTETRICS 

Dupuy (56), in 1905, reported five arthro- which were given in full, with the after- 

plasties. Three were done by Jeannel, one by results. Two others, recent cases, were re- 

Kirmisson, and one by Launay. Jeannel used ported with good immediate results. In three 

flaps of the brachialis anticus; Kirmisson, of cases the histories were unknown. Of the 

the biceps; Launay, a flap from the anterior others, nineteen had useful arms, although one 

ligament and the brachialis anticus. In all was a flail joint which lacked power, but could 

cases good results were obtained. be controlled by the muscles. The poor re- 

Huguier (94, a), in 1905, reported two cases suits in the other cases were due to extreme 

operated on by Nelaton with the interposition atrophy of the muscles, and to extensive re- 

of a muscle flap. In one case he gained good section of the diseased tissue. Re-ankylosis 

motion. Huguier reported a third case by occurred in two cases. In one, it was due to 

Ombredanne, using the same method. operation too soon after trauma, a fracture 

Pereira (135), in 1906, in an unreduced sub- luxation, and lack of after-treatment. In the 

luxation, resected the ends of the bones and other case, Reiner attributes the result to the 

interposed a flap of triceps muscle, with an disease, myositis ossificans, 

almost perfect functional result. Thorn (179), in 1910, reported a case of 

Scudder (166), in 1906, 1907, and 1908, re- ankylosed elbow operated on by Ritter. He 

ported several successful cases in which he used freely transplanted fascia lata as an insert 

used Murphy's method. after the parts had been made freely movable. 

In 1907, Bazy (12) reported a case in which On discharge there was 65 degrees flexion 

he used a flap from the brachialis anticus. and 100 degrees extension. Pronation and 

Nine months later, the function of the arm supination, which were very slight before the 

was almost perfect. operation, were unchanged. 

Ameyaga (5), in 1907, brought his method Wille (195), in 1911, interposed supinator 

of treatment to general attention. The two longus fascia, with good results, gaining 95 

main factors of his technique are the forma- degrees motion. 

tion of a new socket in the humerus and the Osgood (131), in 1911, reported a case of 

firm grasp of the humerus by the hook of the elbow operation, using Baer's membrane, 

ulna. One difficult case he reported had a good Four months after operation, extension was 

success, the patient in 3 years working in a complete, there was voluntary flexion to 120 

factory and carrying heavy weights. degrees, and a little more than normal "lat- 

Stein (173), 1907, cited three successful cases eral mobility. " (Just what Osgood means by 

from Bier's clinic. Triceps flaps were used. "lateral mobility" is hard to understand, as a 

Wiener (194), in 1909, treated an elbow good arthroplasty has none.) 

ankylosed as a result of fracture. A flap of Whitman (193) reported two cases of 

fascia and subcutaneous fatty tissue from the arthroplasty of the elbow in which he used 

triceps was inserted. Twenty days after Murphy's method. 

operation, he broke up the adhesions. Eight- Edmunds (59), in 1912, reported an elbow 

een months later, the patient could carry ankylosis following fracture, in which this 

heavy bundles, and motion was improving. method was also used. At the time of the 

Huguier (94, b), in the same year, mobilized report, active motion was not possible, on 

an elbow, using a flap of brachialis anticus. account of the great atrophy of the muscles. 

In 16 months, the patient could touch his Denk (51) reported two of von Eiselberg's 

shoulder with the hand and extend the fore- cases, in which elbow joints were mobilized 

arm to 150 degrees. with free fascia transplants, with good func- 

Cifuentes (35) reported, in the same year, a tional results, 
similar arthroplasty in which, 1 month after Neff (122) reported a case in which he inter- 
file operation, he obtained a good functional posed a pedunculated triceps aponeurosis flap 
result, with normal movements. between the humerus and ulna and the radius 

Reiner (149), in 1910, reported a series of and ulna. Seven months after the operation, 

twenty-eight arthroplasties, twenty-five of there was active painless motion of 180 degrees 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS n 

and 30 degrees, and only slight lateral mobility. Medical Society of Jena. In others, the 

The joints of the wrist and hand, which were ankylosis had resulted from trauma, neisserian 

previously partially ankylosed, regained from infection, and tuberculosis, 

one-third to one-half their normal range of Exner (62) reported a case 14 months after 

mobility, with the return of function to the an arthroplasty in which a free flap of fascia 

elbow. lata was interposed. The arm was somewhat 

Delbert (49), in 191 2, reported having done unstable, but gave good function. The patient 

nine resections of the elbow with articular could lift heavy weights. At the same time 

grafts. Most of these were too recent to Pupovac reported a second case by the same 

determine the results, but he reported in method. 

detail two cases of a year's duration in which Darling (43) reported an arthroplasty with 

the results appeared to be permanent. In one the use of a pedunculated flap done in the 

of these, he used cartilage from an ankle joint; presence of active infection. The immediate 

in the other, cartilage from an elbow. Both result was good, 

gave good functional results. Harris (79), in 1914, reported two elbow 

Chaput (32, a) reported three cases in which cases by the Murphy method. In one he 

he resected from the thigh a flap of fat the gained 75 degrees motion. In the other there 

size of the palm, and encapsulated the lower was 60 degrees motion. 

end of the humerus with it, suturing it to the Turner (184) reported an arthroplasty of 

neighboring muscles by anteroposterior and the elbow for an ankylosis following a severe 

lateral sutures. osteomyelitis. There had been a musculospiral 

Conrad (37), in 1912, published a disserta- paralysis from which the patient made a per- 

tion on the use of muscle flaps as interposing feet recovery. The elbow had entirely healed, 

material. I have been unable to obtain a copy but, at the time of operation, a small area of 

of this thesis. latent infection was found. Turner used a 

Pomponi (141) advocated the use of a posterior skin incision and inserted a flap of 

pedunculated fascial flap by the method of fascia lata. The elbow was put up in exten- 

Durante. He cited one case in which he sion. The next day there was a recurrence of 

gained complete pronation and supination, the paralysis with signs of local infection, 

nearly normal extension, and flexion to 60 Later, fearing re-ankylosis, he manipulated 

degrees. the elbow under ether into extreme flexion. 

Murphy (120, b) reported twelve arthro- Six months later, the boy had motion from 

plasties on the elbow, using pedunculated fat 50 degrees to 1 20 degrees, and a useful arm, 

and fascia flap. though the muscles were still atrophied. 

Mauclaire (112) mobilized an elbow, using Murphy (i2o,c), in the same year, cited two 

cartilage from the astragalus to cover the cases operated on by his usual method. One 

defects. One fragment was put on the lower patient left the hospital in 5 weeks, with free 

end of the humerus and another between the flexion and extension within an arc of about 45 

radius and ulna. A roentgenogram later degrees. The other patient, one year after 

showed these grafts fused to the bone. the operation, had motion to 120 degrees. 

Putti (145, a), in 1913, reported his arthro- Vulpius (188) prefers pedunculated flaps, 

plasties to date. These included twelve elbow but also uses free flaps of fat, or fascia and fat, 

cases in which he used Kocher's incision and or Baer's membrane. 

a free flap of fascia lata. He obtained stable Durante (58), in 1914, interposed a flap of 

joints, with a useful degree of motion. the sturdy aponeurosis taken from the fore- 

Roepke (156) reported ten cases of ankylosis arm. This method is indicated particularly in 

of the elbow in which he did arthroplasties, extended and hyperextended ankylosis and in 

using free fat flaps to interpose between the cases at a right angle. 

joints. He advised against beginning passive Simon (171), in 1914, in operating for 

motion too soon. One case of arthritis ankylosis in a position of extension of about 

deformans was shown in 191 1 before the 170 degrees, used a longitudinal incision and a 



12 SURGERY, GYNECOLOGY AND OBSTETRICS 

pedunculated flap from the fascia of the upper degrees of motion. Seven weeks after opera- 
arm. The result was the ability to bend the tion, there was good pronation and supination, 
elbow almost to a right angle and to extend it and perfect freedom of motion, 
at least to 170 degrees. Ashhurst (7) uses an incision along the 

Payr (134, a) emphasizes the importance of external supracondylar line and the external 

removing the capsule, or at least the synovia condyle, detached from the humerus with an 

as well as the fibrous cartilage. He has met osteotome. A pedunculated flap is inserted, 

with secondary dislocations and loose joints and the external condyle replaced by means of 

only in some of his first knee cases. The initial a Lambotte self-boring screw. He reports five 

gain in motion is preserved, or even increased, cases. In these cases there were three good 

with use. He had trouble with persistent end-results. One case had a flail joint with 

swelling, especially in cases where this had very slight power of extension. The fifth case 

existed for a considerable time before opera- had a limited motion, but the patient refused 

tion, or had been marked. He believes con- forcible manipulation. 

valescence is shortened by waiting until the Gilbert (68) cited a case of dislocation of the 

swelling has subsided. If re-operation is elbow which had existed 3 months. Good use 

needed, he advises waiting at least 6 months, of the joint was obtained after a Murphy 

In 19 14, his first case was 4 years old. He re- arthroplasty. 

ports twenty-two arthroplasties, of which Tubby (182, a) reported one elbow case in 

three were elbows, one with a good result and which he used a muscle flap. At the time of 

two with very good results. He believes that, the arthroplasty, insufficient bone was re- 

if the indications are correct and the technique moved and re-ankylosis took place. Eight 

and after-treatment good, a favorable result is months later, he did a secondary operation to 

to be expected in 70 to 80 per cent of the remove the mass of new bone. After this 

operations. intervention, all movements were free, but the 

Pupovac (144) reported a case of a girl of elbow was slightly flail, 

nineteen whose elbow had become ankylosed Chaput (32, b) reported a case of arthro- 

at 130 degrees as the result of a severe plasty for ankylosis following luxation of the 

arthritis. He did an arthroplasty, using a elbow. He used two lateral pedunculated flaps 

posterior incision and a free fascial flap, and and sewed the skin up tight. The arm was 

gained motion from 105 degrees to 140 de- put up in a sterile dressing in extension. The 

grees. Five months later, he reopened the following day the arm was flexed, and flexion 

joint and removed some exuberant bone that was complete and vigorous. He attributes the 

united the humerus with the ulna. He gained good result to sewing up the wound without 

70 degrees to 130 degrees motion. drainage and to the immediate mobilization. 

Davis (46) thinks that we should be con- Graff (73) described a case in which he inter- 

servative about opening a joint ankylosed by posed a flap of triceps muscle with almost com- 

tuberculosis. He finds the elbow one of the plete return of normal motion, 

most satisfactory joints for an arthroplasty, Kennedy (98) cited a case in which a 

as well as for an excision, but the results with pedunculated flap was used. The end-result 

the former are much more satisfactory. An is not reported. 

excision requires the removal of 1 to 1.5 inches Murphy (120, d) reported a case showing 

of bone to ensure movement, but, with an perfect motion 7 months after arthroplasty 

arthroplasty, only sufficient bone need be re- for ankylosis from a fracture. A second 

moved to interpose the flap, and it is almost ankylosis from tuberculosis showed a good 

certain to give a stable joint. He used two end-result. 

pedunculated flaps, one from either side. The Whitman (193) exhibited before the New 

joint, he believes, should have drainage. York Surgical Society a case in which an 

Murphy (120, a) reported in 1 91 5 a case of arthroplasty had been done for a fibrous 

ankylosis following fracture. The elbow was ankylosis following tuberculosis. Four years 

ankylosed at about 150 degrees with a few before, an arthroplasty had been clone using a 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 13 

pedunculated flap. At the second operation, process. To ensure pronation and supination, 

the fibrous ankylosis was found to have be- he interposed a small muscular flap between 

come bony. Whitman used a flap of fascia lata the radius and ulna according to the process 

at this operation. He believes that, in an of Huguier. The olecranon was nailed in 

ankylosis following tuberculosis, a free fascial place. Movements were started in 10 days, 

transplant is essential to success, as the In 8 months there was complete active exten- 

tissues about the joint are atrophied. His case sion, flexion at an angle of 40 degrees, good 

showed a perfect end-result, with normal movement, pronation was somewhat fettered, 

flexion and 165 degrees of extension. and supination was restored. 

Brown (22) gained 80 to 150 degrees of mo- Plummer (140) reported two arthroplasties 

tion in an arthroplasty by the Murphy in which he used pedunculated fat and fascia 

method. The arm had been ankylosed in ex- flaps. One of his cases became infected, and 

tension following acute metastatic arthritis. subsequently a portion of the end of the 

Rovsing (159) reported before the Northern humerus had to be removed. The resulting 

Surgical Society two successful cases in which joint was somewhat flail, but gave good func- 

the Murphy method was used. The ankylosis tion. His second case also had good motion, 

was the result of fracture. In the discussion, but facility for moving joint was not good. 

Bergman and Haglund expressed the opinion Ryerson (160) gives in detail his operative 

that mobilization of the knee should not be technique in arthroplasty on the elbow joint, 

attempted. He uses a long posterior incision, avoiding 

Moszkowicz (119), in his report in 1916 on the olecranon. The triceps tendon is cut and 

his operation on war injuries to joints, gives a thin shell of bone is removed from the ex- 

among other cases six elbow arthroplasties, ternal condyle, taking the origin of the ex- 

In all of these a useful degree of motion was tensor with it. Then a shell from the internal 

gained. condyle is removed. The joint is dislocated. 

Ringel (151), in 1916, mobilized five cases of After it is remodeled, a flap of fascia lata is 

complete ankylosis of the elbow and implanted interposed. 

fat and fascia flaps. One good result was ob- Thomson (180) reports the end-results in an 

tained; three cases were being treated when elbow arthroplasty by the Murphy method, 

he reported, and in the other case suppuration Ankylosis was the result of sepsis following a 

developed. fracture. Seven months later, elbow motion 

Four cases of mobilization of the elbow, in was good, but somewhat restricted. His 
which flaps of fat were interposed, were re- successful cases have all been traumatic. He 
ported by Werde (190), in 1916. He obtained believes that neisserian infection is a contra- 
normal motion in all cases. indication to arthroplasty, as it stimulates 

Steindler (174), in 1916, reported two opera- bone formation. Tuberculosis is also a contra- 

tions. In one of ankylosis of the humerus, a indication, on account of the recrudescence of 

pedunculated muscle flap was used. Mobility the disease. 

was good as long as the patient was under A brief mention is made by Prando (142) of 

observation. The end-result is not reported, a case using a modification of the Murphy 

The other case followed fracture of the head method. He did not use an Esmarch bandage, 

of the radius, resulting in partial ankylosis. A and enveloped the ulnar nerve in a flap of 

pedunculated fascia flap was inserted. In two muscle taken from the triceps. He is satisfied 

weeks range of motion was about normal. with his results. He also reports a case in 

Crosti (41), in 1916, presented a case in which Padman followed the Murphy method, 
which he had interposed an aponeurosis flap Satisfactory motion was obtained, but later 
taken posteriorly from the forearm. Complete the joint re-ankylosed. Prando believes that 
bony union at an angle of 130 degrees was a the Murphy method is very good, although it 
result of fracture from a shell. There was a cannot be so successful as orthopedic re- 
vast amount of cicatrix. The olecranon was section, on account of the great danger which 
temporarily detached according to Durante's the slightest negligence involves. 



i 4 SURGERY, GYNECOLOGY AND OBSTETRICS 

Ceccarelli (31) used strips of fascia lata in other from acute rheumatism. Good active 

an arthroplasty on a post- traumatic ankylosed and passive motion to a sharp angle were 

elbow. The end-result was perfect flexion, secured, extension was complete, and prona- 

extension to 165 , and almost normal pro- tion and supination amounted to 60 degrees, 

nation and supination. Grange (74), in 1920, used a flap of fat from 

Olivieri (128) reports two arthroplasties the posterior surface of the triceps and a piece 

with interposition of strips of brachialis anti- of cargile membrane on each side of the flap 

cus. The end-results were perfect. in an arthroplasty for complete ankylosis of 

Hohmann (89), in 19 18, reported five elbow the elbow at an angle of 90 degrees. The 

arthroplasties in which he inserted part of the joint was reached through an incision 4 inches 

triceps with good immediate results. Lange long on the outer and inner side of the joint 

at the same time showed six cases in which and a transverse incision across the arm above 

useful joints were obtained and the patients the olecranon. The ulnar nerve was dissected, 

were enabled to resume their old occupations, the triceps muscle divided, and the humerus 

He used fat or muscle flaps. exposed. Flexion of 30 degrees beyond a right 

Baer (9,a), in 1918, reported having done to angle and extension of 45 degrees from a right 

date three arthroplasties on the elbow joint, angle were secured. The pronation and supi- 

In one, re-ankylosis occurred, one patient nation amounted to about 30 degrees, due per- 

died, and the third showed 25 degrees motion, haps to too little excision of bone. 

He believes that the elbow is the least favorable Kerr (99) cited a case of complete ankylosis 

joint for arthroplasty, and that the success of the elbow following arthritis. He used 

from the interposition of muscle or fascial Kocher's incision and inserted periarticular 

flaps is due to the amount of bone removed fascia. The result was a movable, useful 

rather than to the flap itself, and that these joint, with no atrophy of the muscles, 

operations are in fact only excisions. In the Verral (187), in 1920, described his method 

discussion of this paper, Galloway and Frei- of operation. He makes an eight-inch incision 

berg express the opinion that an arthroplasty along back of the elbow. The triceps tendon 

has no advantage over an excision. Davis is divided in two layers to overlap when 

states that with an arthroplasty a more stable sutured. A fascia flap is sutured over the end 

joint is obtained. of the humerus. The elbow is put at about 

Albee (3) uses a vertical incision directly 120 degrees, 

over the olecranon. After retracting the ulnar Rocher (153), in 1920, applied Putti's 

nerve and dissecting the soft tissues, he saws technique, using a flap of aponeurosis fascia 

through the olecranon from within outward, lata in operating for a case of fibrous ankylosis 

He remodels the joint and interposes a flap of of the elbow in an almost rectilinear position, 

fascia lata containing as much fatty tissue as He secured a perfect functional result of 

possible. The arm is put in plaster at right voluntary flexion to 80 degrees and pronation 

angles. After 10 days, passive motion is of 45 degrees, 

begun. Silfverskiold (170), in 1922, reported an 

Henderson (81), in 1918, tabulated the end- arthroplasty, using flap of fascia lata. In 

results of the forty-three arthroplasties done eight months the patient showed full active 

at the Mayo Clinic. Twenty-one of these were capacity for flexion and extension, 

on the elbow. He found the prognosis most Campbell (26,b) has just published his 

favorable in the jaw and next in the elbow, method for arthroplasty of the elbow, which 

The knee was the most unfavorable position, is evolved from his method for reduction of 

In reports from other surgeons he found a old dislocations. An incision 6 to 8 inches 

general agreement as to prognosis. long is made on the posterior aspect of the 

Kleinschmidt (102), in 1919, demonstrated arm and forearm. The skin and fascia are 

two cases in which he secured mobility, using incised and the deep fascia dissected laterally 

Payr's method. One case of complete ankylo- about one inch. The suture is then dissected 

sis had resulted from a shot wound and the downward, making a long tongue flap. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



i5 





Fig. 1. Line of incision used by 
the author. 



Fig. 2. Dissecting out the ulnar 



nerve. 



Fig. 3. Cutting through the muscle 
and fascia down to the joint. 



Through a further incision the periosteum is 
stripped from the lower third of the humerus. 
A half-inch of bone is removed from the 
humerus and the end modeled into a surface 
convex from before backward. A half- inch of 
bone is then removed from the tip of the 
olecranon process. The surface of the head of 



the radius is made the same level as the 
coronoid process. The periosteum and triceps 
are dissected into a double flap, which is 
stitched to the anterior capsule. One case of 
ankylosis as a result of acute infectious 
arthritis, operated on by the above method, 
in 6 months resulted in complete extension 






Fig. 4. Sawing through olecranon 
and end of humerus. 



Fig. 5. Splitting off tip of ole- 
cranon with chisel. 



Fig. 6. Removing with rongeur for- 
ceps bit of olecranon tip left in humerus. 



i6 



SURGERY, GYNECOLOGY AND OBSTETRICS 




?•?"■' 



• uU . ><■ 





&? 



<$'<$*. 



Fig. 7. Scooping out ulna and 
radius with curette. 



Fig. 8. Cutting fascia lata from 
thigh. 



Fig. o. Sewing flap of fascia lata to 
elbow joint anteriorly. 



with flexion to 60 degrees. Physiotherapy is 
being used to increase the flexion. 

In case of a normal radio-humeral joint 
with bony ankylosis between the ulna and 
humerus, a hemi-arthroplasty is done between 
the humerus and ulna and a broad aponeurotic 
tongue flap from the triceps interposed. The 
one case reported, of solid bony ankylosis, in 
six months resulted in 50 per cent of the 
normal motion. 

The after-treatment is very important, and 
active motion is essential. 

Operative technique — author's method. The 
arm from the wrist to the shoulder and the 
leg on the same side, from the hip to the knee, 
are given a two-day preparation. At the time 
of the operation, a tourniquet is applied to the 
upper third of the arm and an application of 
iodine made to the skin. 

A semicircular incision is then made, begin- 
ning over the external condyle (Fig. 1), run- 
ning down about two inches and up over the 
internal condyle. The wound is sponged with 
alcohol and carefully clamped off to avoid 
handling the skin during the operation. The 
flap containing skin and superficial fascia is 
then dissected back to the base line and re- 
tracted. The ulnar nerve is isolated and dis- 
sected out of its sheath (Fig. 2). It is some- 



times difficult to find this nerve, but it is al- 
ways to be sought at the inner side of the 
internal condyle. It should be dissected out 
carefully with a blunt dissector so as not to 
injure it. After it has been freed for one and 
one-half inches, gauze is passed beneath the 
nerve, and it is retracted to the ulnar side. 
It is then freed further by blunt dissection 
with gauze. 

A transverse incision is then made extending 
down through the periosteum (Fig. 3). This 
incision follows in direction the superficial one, 
and outlines a flap which is to be dissected 
back and preserved in toto for subsequent 
covering for the joint. The pulling back of this 
flap is a hard and tedious process until it is well 
started, after which it can be peeled back 
readily by blunt dissection. It is the inner 
side that is the hard part, as the layer is thin 
here, and one must exercise great care not to 
buttonhole it. The olecranon is then sawed 
through (Fig. 4). After this, it is frequently 
possible to break open the old joint. In some 
cases, however, ankylosis is bony and the 
joint cavity obliterated. Cases of this kind 
are the most difficult. It is in these cases 
necessary to saw through the joint. The tip 
of the olecranon has to be chiseled out and 
dissected back with its posterior flap. Usually 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



i7 




Fig. 10. Fascia sewed over humer- 
us; tied with chromic catgut suture. 



Fig. 11. Kangaroo suture through 
ulna and olecranon tip. 



Fig. 12. Stay sutures. 



the olecranon is too large, and it is well to take 
off a little of it (Fig. 5). 

The capsule, fascia, and ligaments are then 
dissected back so as to allow the lower end of 
the humerus to protrude into the wound. 
Then its edges are snipped off with rongeur 
forceps and a new trochlear or intercondylar 
surface formed (Fig. 6). A shoemaker's rasp 
is used in filing the extremity as near like the 
normal humeral end as possible. After this 
modeling, a piece is removed corresponding to 
the olecranon fossa in the normal humerus. 
One has to be careful about making this cup, 
as the success of the operation depends largely 
upon attention to such small details (Fig. 7). 
This modeling is largely done with a saw and 
a file. 

To ensure good function, the joint surfaces 
should fit accurately before the fascia is ap- 
plied, but the joint should not be too loose. 
Only sufficient bone must be removed to give 
free motion. If too much of the ends of the 
bones is removed, a flail joint will result, 
giving the operation no advantage over an ex- 
cision. When this mortising is completed, the 
fascial flap is dissected from the leg (Fig. 8). 
An incision is made on the outer side of the 
thigh, a little below the middle, extending 
down to the fascia lata. After a flap of fascia 



5 to 7 inches by 4 to 5 inches wide is dissected 
out, the wound is closed. 

This fascia, which is free from all fat, is 
placed about the newly fashioned humeral 
condyles and attached anteriorly to the cap- 
sule (Fig. 9) and posteriorly to the periosteum 
of the lower end of the shaft of the humerus 
with interrupted chromic catgut sutures No. 2 
(Fig. 10). Chromic catgut No. 2 is then loose- 
ly wound twice around the shaft just below 
the interrupted suture line. 

The forearm is placed in apposition to the 
condyles. Two drill holes are then made in 
the olecranon process and two others opposite 
them in the shaft of the ulna. Through these 
kangaroo tendon is passed and tied (Fig. n). 
The inner layer is now sutured with chromic 
catgut No. 2 and the skin and fascia with 
plain catgut No. 2 (Fig. 12). Dry sterile 
dressings are applied and the arm put up in 
plaster beyond a right angle. 

After-treatment. If there is no evidence of 
infection, the cast should remain on for a 
week. It is then split and the dressing changed. 
If there is a persistent temperature, a window 
should be cut in the cast and the wound in- 
spected. 

Passive motions are begun in about 10 days, 
if normal healing has taken place. The arm is 



i8 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 13. Case 1. E. S. Roentgenogram showing position 
of ankylosis before arthroplasty. 

always kept above a right angle. After 3 
weeks, gentle massage is applied. Baking is 
begun in 6 weeks, three or four times a week. 
The ultimate success in these cases depends 
very largely on the after-treatment. The 
patients should be under observation for a 
long period of time. Frequent X-rays should 
be taken so that we may follow the bony 
changes in the joint. If motion begins to shut 
down, the arm should be manipulated under 
an anaesthetic and the elbow put up in acute 
flexion. Occasionally motion becomes limited, 
due to an exuberant growth of new bone. In 
this case, a secondary operation should be done 
to remove this, but it should not be under- 
taken for at least 3 months after the original 
operation. 

Case i. E. S. was admitted to the Carney 
Hospital, August 11, 19 13, for immobility of the 
right elbow and right knee. Six years previously, 
the patient had had an acute illness accompanied by 
fever and pain and swelling in the joints, for which 
she was treated in her home, without relief. At the 
end of 8 months, the pain and swelling had dis- 
appeared from her left shoulder and elbow so that 
she was able to feed herself, but she remained in 
bed for 12 months and after this was in a wheel-chair 





Fig. 14. Case 1. E. S. End-result, 5 years and 10 months 
after arthroplasty. At left, voluntary flexion; at right, 
voluntary extension. 



Fig. 15. Case 1. E. S. Lateral roentgenogram, 5 years, 
10 months after arthroplasty. 

for 2 years. The symptoms continued to subside and 
the pain and swelling disappeared; fairly good motion 
returned to all the joints except the right elbow and 
the right knee, in which pain and stiffness con- 
tinued at the end of the fourth year, and no motion 
was possible. This condition continued up to the 
time of admission. 

August 14, 1 913, roentgenoscopy revealed an 
ankylosis of the elbow joint and of the patella to the 
femur (Fig. 13). 

August 20, 1913, 1 did an arthroplasty of the right 
elbow using a flap of fascia lata. A light plaster cast 
was applied. Following the operation, the patient 
made a good ether recovery. There was slight pain 
in the elbow. 

August 27, 1913, the cast was split for dressing. 

September 1, 1913, the wound had healed by first 
intention except for a slight discharge on the upper 
border. 

September 4, 1913, daily manipulation of the 
elbow was ordered. 

September 10, 1913, the arm could be extended 
completely and flexed to 15 degrees beyond a right 
angle. 

September 15, 1913, traction was applied for flex- 
ing and extending the arm. 

October 1, 1913, active motion was possible. 

October 15, 1913, I manipulated the arm under 
ethyl chloride. 

May 15, 1 91 9, 5 years and 10 months after opera- 
tion, she writes: "The arm is doing excellent work. " 
Photographs taken at this time show practically full 
extension and flexion (Figs. 14 and 15). 

Case 2. E. S. sustained a fracture of the right 
elbow on October 4, 1913, as the result of a fall of 
42 feet. The roentgenogram showed a transverse 
fracture of both condyles with the radial head dis- 
located laterally and anteriorly. 

Physical examination was negative except for the 
right arm. The shoulder appeared normal. The 
elbow was held at 150 degrees extension with less 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



19 



than 3 degrees motion. Supination was limited one- 
fourth. The wrist showed a Colles fracture un- 
reduced. Flexion and extension were both one-half 
normal. Eversion was limited three-fourths and 
inversion four-fifths (Fig. 16). 

On March 25, 1914, I did an arthroplasty on the 
right elbow, using a flap of fascia from the thigh. 
When the joint cavity was opened, it was found that 
the synovial tissue was hypertrophied, and there 
was much fibrous callous formation infiltrating the 
articular surfaces. A transverse fracture of both 
condyles was noted. The head of the radius was 
impacted, and was surrounded by callous formation. 

Five-eighths of an inch of the condyles was sawed 
off square at right angles to the shaft of the humerus. 
The joint surfaces were smoothed off and the opera- 
tion completed according to my usual method. The 
arm was put up in plaster in an extended position. 
The patient made a good ether recovery, but suffered 
considerably from pain, for which morphia was 
ordered, and the following day the arm was put up 
in suspension. He continued to suffer considerable 
pain for 4 days, after which it abated. 

On March 29, 1914, the wound was dressed, and 
was found clean except for some serous discharge. 

March 30, 1914, the cast was split and a volumi- 
nous dressing applied with splints to the forearm. 

March 31, 1914, the patient was seen in consulta- 
tion by Dr. Courtney, who reported a tourniquet 
paralysis, and advised electricity and massage. 

April 1, 1914, the wound was dressed, and found 
clean and healing by second intention. Electricity 
and massage daily. 

April 5, 1914, the patient was out of bed and walk- 
ing about the ward. When dressed, the wound was 
found clean. 

April 10, 1914, the wound was dressed. The 
motion in the elbow was good, with supination and 
about 45 degrees motion in flexion. A nerve report 
was ordered. 

April 15, 1914, the nerves were reported respond- 
ing to the faradic current. The prognosis was con- 
sidered good. Massage was advised. 

April 18, 1914, the patient was discharged from 
the hospital to report daily at my office. 

November 30, 1914, the patient re-entered the 
hospital for operative interference in an attempt to 
gain increased motion. Both bones of the forearm 




Fig. 16. Case 2. E. S. 
losis before arthroplasty. 



Roentgenogram showing anky- 



had dislocated backward and the head of the radius 
was very much enlarged. Motion was from 150 
degrees extension to 50 degrees flexion with the 
carrying angle markedly increased. 

On December 2, 1914, after the usual preparation, 
a four-inch incision was made over the external 
condyle. The removal of the enlarged head of the 
radius caused a marked increase in motion, but the 
posterior dislocation was not improved. The internal 
condyle was chiseled loose and removed through a 
small incision over the fragment. After the end of 
the humerus was smoothed as much as possible with 
a rasp, the wound was closed and a cast applied with 
the arm at right angles. A good ether recovery 
followed. 

After the operation, the patient suffered con- 
siderably and showed some swelling of the arm. 
On the fourth day, the cast was split, and the 
patient experienced relief. 

On the seventh, the patient was comfortable and 
out of bed. The following day he was discharged, to 
report to my office. 

The end-result shows nearly normal range of 
motion with a stable, useful joint. 

On October 29, 1920, he writes: "I can crank a 
Ford. I can do anything that I ever could. My 
work is driving and repairing automobiles, and I 
have had to change 38-7 tires on the road, which 
requires the use of two good arms." (Fig. 17.) 

Case 3. F. D. In 1910, the right elbow became 
swollen and tender. At this time an open operation 




c. 



Fig. 17. Case 2. E. S. End-result, 6 years, 6 months after arthroplasty, a, voluntary flexion; b, voluntary exten- 
sion; c, range of motion. 



20 



SURGERY, GYNECOLOGY AND OBSTETRICS 




r 



Fig. 18. Case 3. F. D. End-result, 1 year and 4 months 
after arthroplasty. Below, voluntary flexion; above, 
voluntary extension. 



was done on the joint. Six months Jater, another 
operation was done after which the elbow drained 
for 4 years and the patient lost the entire use of the 
arm. There were numerous scars above and about 
the elbow. The elbow was ankylosed at 180 degrees. 
Finger and shoulder motions were normal. 

On August 10, 1918, by the usual method, I did an 
arthroplasty on his elbow. He made a good recovery 
and had a normal convalescence. Two weeks later, 
he was discharged to have daily dressings done by 
the family doctor. Motion at this time was from 
80 degrees to 100 degrees without pain. 

He reported at my office on August 30, 1918. At 
this time the wound was quite healed. The elbow 
showed 30 degrees motion. He was then seen about 
every 6 weeks. On October 18, 1918, the wound was 
found healed. Motion gradually increased 

On December 9, 1919, he showed motion from 35 
degrees to 145 degrees, with full supination. The 
elbow was stable, with no lateral motion. He has no 
pain, works as a telegraph operator, and "lifts any- 
thing." (Figs. 18 and 19.) 

Case 4. E. M. This patient's trouble started 
slowly with general poor health. Two years ago, she 
became ill with infectious arthritis, which at first 
affected the knees. There was no history of a 
neisserian infection. The patient was very much 




Fig. 19. Case 3. F. D. End-result, 1 year and 4 months 
after arthroplasty. Voluntary extension. 

constipated and suffered more or less from tonsillitis. 
Later, the elbows became painful and could not be 
straightened out. 

Physical examination showed a thickening of the 
capsule of the left elbow, with about 35 degrees 
limitation in motion. The left knee showed ex- 
tension to within 15 degrees of full extension. The 
patient walked with a marked limp, and flexed knees. 
General treatment was prescribed, with forcible 
extension of the knees. As motion in the arm had 
shut down leaving it ankylosed at 100 degrees, an 
arthroplasty on this joint was advised. 

February 25, 1913, I did an arthroplasty, using 
my fascia lata method. 

March 24, 1913, the arm showed no swelling. 
There was little pain and the patient's general con- 
dition was fair. There was about 1 5 degrees motion. 
Gentle manipulation was ordered. 

December 16, 1913, the wound had healed by 
first intention; supination was three-quarters normal, 
extension was to 170 degrees and flexion to 10 
degrees to 15 degrees beyond a right angle. The 
patient could reach the opposite shoulder with the 
thumb with ease, but could not dress the lower part 
of the hair. The muscular power was as good as in 
the right arm. To gain more motion, a forcible 
manipulation was advised. 

December 29, 1913, under ether, extension to 
within 5 degrees of straight was obtained and flexion 
to 45 degrees. 

January 26, 1914, examination of the arm showed 
no lateral mobility and no crunching crepitation. 
Mobility was from 55 degrees to 145 degrees. 
(Figs. 20 and 21.) 

Case 5. S. S. This patient was first admitted to 
the Burbank Hospital, Fitchburg, December 5, 
191 7, with a subacute neisserian infection. Five 
years previously the right knee had become swollen, 
and remained so for 3 months. A month later, the 
right elbow became swollen and painful. _ The 
Wassermann test was positive. She remained in the 
hospital 38 days, receiving general treatment, and 
was discharged relieved. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



21 



She returned to the out-patient department July 
i, 1918. The arm was then put up in plaster from 
wrist to shoulder to remain on 2 months. She was 
told that her elbow would probably become stiff 
and would require an arthroplasty later. 

On January 9, 1919, the patient was advised to 
have an arthroplasty done as her elbow had become 
stiff. Following the operation on February 6, she 
had an uneventful recovery. The cast was removed 
in 2 weeks, after which passive motion was begun. 
She was discharged March 18, 1919 (Figs. 22 and 

23)- 
Case 6. M. R. For 13 years this patient had had 

attacks of rheumatism affecting the ankles, elbows, 

and knees. The physical examination was negative 

except for the joints. Both knees were slightly 

flexed and the right one was ankylosed, showing 

scars on either side. The right ankle showed some 

contraction of the tendo-achillis. The left elbow 

showed good motion except for 10 degrees limitation 

in extension; the right was ankylosed at 125 degrees. 

The patient was admitted to the orthopedic 
service of the Carney Hospital, September 6, 1910, 
where very slight improvement took place in the 
knees and feet under conservative treatment. In 
October, 1910, on account of the swelling and boggi- 
ness of the left knee, an arthrotomy was advised. 
This was done October 19, 1910. Daily manipulations 
were begun on the fifth day, and an uneventful 
recovery took place as regards the knee. 

As the elbow was stiff and in an ungainly position, 
operation on this joint was advised. On November 
5, 1910, an arthroplasty by the Murphy method was 
done on this joint. 

November 10, 1910, the right hand was consider- 
ably swollen and painful, for which pressure and hot 
fomentations were applied. The skin on the upper 
part of the arm became somewhat necrotic from 
poor circulation and later sloughed. 

November 30, 1910, passive motion was begun 
and repeated daily. The first attempt at motion was 
made and 30 degrees attained. Following this, 
progress was continuous and a gradual gain in 




Fig. 20. Case 4. E. M. Above, lateral roentgenogram 
10 months after arthroplasty; below, anteroposterior 
roentgenogram. 

motion was made. Later, massage was ordered for 
the hand, forearm, and shoulder. 

January 11, 191 1, about 30 degrees to 40 degrees 
of motion in flexion and extension were obtained. 
The wound showed heavy granulation tissue. A 
week later she was discharged from the hospital. 
Dressings were to be done at home. 

February 28, 191 1, she was readmitted to the 
hospital for manipulation. Normal motion was ob- 
tained. Since this time, she has been seen in the out- 
patient department. There is practically no lateral 




Fig. 21. Case 4. E. M. End-result, 10 months after arthroplasty, a voluntary extension; b, voluntary flexion; 
c, range of motion (not in full range). 



22 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 22. Case 5. S. S. Roentgenogram showing anky 
losis before arthroplasty. 



mobility and the end-result is perfect function 
(Figs. 24 and 25). 

For a full report of elbow arthroplasty, the 
reader is referred to the author's (111) articles 
appearing in Clinics of North America, Jour- 
nal of the American Medical Association, and 
Surgery, Gynecology and Obstetrics. 

knee 

The knee joint presents a greater barrier to 
good arthroplastic work than any of the other 
large joints. Lateral stability and security in 
the knee must be almost absolute. Without 
stability, a brace is necessary to permit walk- 
ing; even the use of a brace will not prevent 
the progress of overgrowth of bone (a direct 
result of undue strain) , with its accompanying 
pain and soreness. A stiff knee, on the other 
hand, is a good functional member if the 
ankylosis is firm and in good position (5 de- 
grees to 8 degrees of flexion). (Figs. 26 and 
27.) 



Fig. 23. Case 5. S. S. End-result, 1 year and 4 months 
after arthroplasty. At left, voluntary flexion; at right, 
voluntary extension. 

If we consider arthroplastic measures in a 
single ankylosis of the knee, they must be 
cautiously advised, even in face of the ad- 
vances that have been made, largely by the 
splendid work of Professor V. Putti, of 
Bologna. Arthroplasty must be done with 
the assurance of stability and freedom from 
sensitiveness and pain. In other words, we 
must increase function in order to classify the 
result as good or improved. 





Fig. 24. Case 6. M. R. Roentgenogram showing anky- 
losis before arthroplasty. 



Fig. 25. Case 6. M. R. End-result, 1 year and 3 months 
after operation, a, voluntary flexion; b, voluntary exten- 
sion; c, range of motion. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



23 



Progress is fast being made, and, although 
undoubtedly the last 5 years have seen a great 
advance in the number of functional results, 
we expect better ones in the future. 

Generally speaking, an ankylosis, bony in 
character, lends itself best to mobilization, as 
it is more free from the results of tissue in- 
fection. Such a condition is true of all joints. 

In general, the results of fascia transplanta- 
tion have proved most successful, and the 
technique as advised by Putti has given the 
most consistent results. I differ from his 
technique only in believing it advisable not to 
sever or disturb the patella tendon or its 
attachment. 

Operative technique — author's method. The 
usual preparation is given both legs from the 
ankle to the groin. I feel it is best to remove 
the fascia from the opposite leg, thereby 
minimizing the extent of the operation on the 
ankylosed leg as well as making it possible to 
remove more fascia without disturbing the 
external support of the joint. 

The incision is made from just below the 
inner attachment of the patella tendon, curv- 
ing slowly over this point to the middle of the 
external cartilage, and then directly up the 
outer side of the leg just above the mid- 
horizontal line, a distance of 5 to 10 inches 
from the joint proper (Fig. 28). As much fat 
as possible is taken with this incision. After 
clamping the skin-edges with towels, the skin 
is dissected to the inner side of the leg, expos- 
ing the patella tendon, patella, and tibial 
tubercle. 

A curved incision is then made through the 
fascia, beginning in the mid-anterior line, 
about 5 inches above the patella, and running 
between the patella and outer condyle to just 
below the knee joint. 

The quadriceps tendon is then exposed and 
elongated. This elongation not only allows 
better joint exposure, but affords a proper 
lengthening when we later place the leg in 
flexion in plaster. This lengthening may also 
be done by the Bennett method (Fig. 29). 
The patella is then raised from the femur, 
taking the lower cut portion of the quadriceps 
tendon, and forcibly retracted to the inner 
side of the knee, with its inner ligament at- 
tachments intact. Some surgeons detach a 





Fig. 26 (at left). Ankylosis of knee, normal position. 
Fig. 27. Ankylosis of knee, 30 degrees flexion. 

piece of the tibial tubercle in order to increase 
exposure, but I have found this unnecessary 
when the quadriceps tendon is elongated in 
the beginning. There are also many difficulties 
when this piece is removed, such as delayed or 
faulty union, which complicate the con- 
valescence (Fig. 31, see frontispiece). 

The patella in these cases is often found 
hypertrophied and should be narrowed later- 
ally, as well as thinned and smoothed with a 
shoemaker's rasp. 

The joint being then exposed, a careful 
study of it is made from X-rays, and great 
care is taken to follow the contour carefully. 
Putti instruments are admirable for this 
purpose (Fig. 30). 

Several important requirements must be 
observed : 

1. Be sure to leave a well-defined spine 
between the tibia condyle, as well as cup 
out the upper tibia surface, which will help 
stabilize lateral mobility (Figs. 32 and 33). 

2 . Carefully round the condyle with a Putti 
instrument and a shoemaker's rasp, making a 
concavity to fit over the newly formed spine. 

3 . Actually replace these opposing surfaces, 
and mold carefully, without any irregular 
hitches during attempts to flex. 

4. Cup out a space into which the patella 
will articulate. Great care should be taken 
with this modeling. 



24 



SURGERY, GYNECOLOGY AND OBSTETRICS 






Fig. 28. Kocher's incision as used in technique em- 
ployed by author. 

5 . Remove a large piece of fascia lata ample 
enough to cover both condyles. The fascia 
nearest the knee on the outer side is thickest 
and most serviceable. When this is removed, 
sew the fascia over the condyle, covering all 
exposed bone well. Sew posteriorly 2 inches 
above the articular surface (Figs. 34 and 
35). The femur is then adjusted to the 
tibia, and the patella is replaced. The outer 
fascia is united with interrupted chromic 
catgut. 

The elongated quadriceps is then strongly 
sutured and the skin closed with interrupted 
catgut (Fig. 36) . A plaster is applied from the 
toe to the groin with the knee in 35 degrees to 
40 degrees flexion and the leg placed in an 
elevated position in bed. Opiates are often 
necessary and may be freely used. 

After-treatment. The temperature, pulse, 
and pain are carefully watched for any signs 
of infection. 




Fig. 30. Putti instruments. 



Fig. 29. Incision through fascia and capsule including 
division of the quadriceps tendon. 1 

The cast is split for dressing in 2 weeks 
and the leg put in a ring caliper with 35 
degrees flexion, so arranged that this can be 
changed and passive motion slowly started. 
Traction is also applied with this caliper which 
remains on day and night. Gentle passive 
motions are started and increased gently, 
guided by pain and sensitiveness, which always 
should be minimized. Massage is started in 5 
to 6 weeks for thigh and calf, and the patient 
may usually walk with crutches about the 
sixth week. By means of an overhead exten- 
sion, the patient may also use passive motions 
in bed, two or three times a day. 

Active motions are started or attempted 
about the tenth week, preferably with the leg 
submerged in a tub of water. No actual 
weight-bearing is allowed until the lateral 
ligaments have tightened, and a caliper may 
be applied to assist weight-bearing, depending 
wholly upon the sensitiveness and pain on use. 

Case 1. F. 0. K., age 31. In 1909, patient had an 
acute neisserian infection in the left knee. The 
opening of the joint resulted in an ankylosis. The 
knee was in good position, but there was no motion 
between the tibia and the femur. The patella was 
ankylosed to the femur. Manipulations were un- 
successful in obtaining motion. Arthroplasty was 
advised. 

December 14, 1910, arthroplasty on left knee 
according to the technique as described. 

December 23, 1910, out of bed. Daily dressings. 

January 5, 191 1, cast removed. Posterior shell 
applied. 

January 7, 191 1, small amount of weight-bearing. 
Crutches. 

January 19, 1911, patient discharged from hos- 
pital. In a leather leglet with limited motion. He is 
to continue stretching and daily hot fomentations. 

January 3, 1923, now 12 years since arthroplasty. 
Patient has no pain and has had no trouble. "No 

1 Figures 31 to 36, detailing further points in author's technique, shown 
in frontispiece. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



25 





. """"^ 



.y 



Fig. 31- 



Fig- 34- 





Fig- 32. 






. - '. 



Fig. 35- 







Fig. 33- 



Fig. 36. 



Fig. 31. Displacement of the patella with inner capsule 
inward and division of ankylosis. 

Figs. 32 and 33. Luxation of the joint and remodeling 
of the femoral and tibial surfaces. Note the exaggeration 
of the spine of the tibia. 



Fig. 34. Attachment of the fascial flap to the posterior 
capsule. 

Fig. 35. Completion of the suture about femoral end. 

Fig. 36. Suture of the capsule and elongated quadri- 
ceps. 



26 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 37. Case 1. F. O'K. Weight- 
bearing, 1 2 years after arthroplasty. 



Fig. 38. Case 1. F. O'K. 
Weight-bearing, 1 2 years 
after arthroplasty. 



Fig. 39. Case 1 . F. O'K. 95 degrees flexion, 
12 years after arthroplasty. 



bother at all and can do everything. Sometimes has 
to stop and think which is the knee operated upon. " 
Has gained 40 to 50 pounds. The leg is straight. He 
has good power in quadriceps. Complete extension is 
possible and he has 95 degrees motion in flexion. He 
has absolutely no lateral mobility. (Figs. 37, 38, 39, 
40, 41.) 

The use of the muscle flap from the vastus 
internus in operations of the knee joint was 
suggested by Helferich (80, b). Cramer (40) 
followed his proposal, and in 1901 reported 
ten operations of ankylosis of the patella by 
interposition of a piece of the vastus internus. 
Six of these were successful. Hoffa (86) re- 
ports eight tibiofemoral cases of his own. He 
used fatty flaps. One case resulted in 15 de- 
grees motion and ability to walk, the second 
in 15 degrees and painful motion, and the 
third in good motion, but with slight limp- 
ing. In three cases ankylosis recurred. The 
seventh case had good walking ability and the 
eighth had 15 degrees motion 7 months after 
the operation. One patella case had 10 de- 
grees motion 2 years after the operation. 
Hoffa believes his results are due to shortening 
and the contraction and atrophy of the exten- 
sor muscles. It is his opinion that the tendon 
should be lengthened by plastic operation or 
the tuberosity chiseled and attached higher up. 



Murphy (120, a) first used his fascia method 
in 1 90 1 on the knee joint. A large layer of 
fascia lata, with a thin layer of muscle at- 
tached, was dissected from the outer surface 
of the vastus externus, with its base below 
and anterior. A small flap of fascia covering 
the vastus internus was dissected free and 




Fig. 40 (at left). Casei. F. O'K. Anteroposterior roent- 
genogram 1 2 years after arthroplasty. 

Fig. 41. Case 1. F. O'K. Lateral roentgenogram 12 
years after arthroplasty. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



27 




Fig. 42. Line of Kocher's incision. The dotted line 
shows the prolongation of the incision which is necessary 
to obtain the flap for transplant. (Putti.) 





Fig. 45. Preparation of fascia lata flap. (Putti.) 



Fig. 43. Detachment of the tibial tubercle and the 
arthrolysis. (Putti.) 





Fig. 44. Luxation of the joint surfaces. (Putti.) 

placed between the patella and the femur. 
Between 191 2 and 1916, Murphy reported 
fourteen operations. While at first he used 
fascia lata from vastus externus, he later used 
two implants of fat and fascia, one lifted from 
the inner and one from the outer aspect of the 
knee. He also changed his incision from two 
vertical cuts to a U-incision. The patella was 
treated in four different ways; by placing a 
flap under it, by turning it turtle, by rotating, 



Fig. 46. Attachment of the flap on the resectioned sur- 
faces. (Putti.) 

or by transplanting a detached flap of the 
trochanter. Of the fourteen cases, there were 
two splendid results, six good weight-bearing 
legs, one showed good flexion and extension 
improving, and three records are incomplete. 
In one, a sheet of paraffin was inserted be- 
neath the patella. 

Since 1901 many attempts to mobilize the 
knee, using Baer's membrane, Cargile mem- 
brane, free and pedunculated flaps of fascia, 
have been reported. 

McCurdy (113) and Osgood (131) used 
Baer's membrane. The former did not report 
on his result, but Osgood found that, although 



28 



SURGERY, GYNECOLOGY AND OBSTETRICS 



good or fair motion resulted, there was some 
lateral motion. These results, I feel, clearly 
show the loss of stability so dangerous to 
function, and do not represent arthroplasty, 
but rather flail joints. 

Tubby (182, a) in 1914 interposed Cargile 
membrane in three cases with one good result. 
In the other cases the patients refused the 
after-treatment. 

Schmerz (164) has had good results in the 
interposition of amnion membrane which he 
claims surpasses the fascia transplantation in 
simplicity and safety. 

Whitacre (192), Neff (122), Owen (132), 
Quigley (147), Tubby (182, a), Pringle (143), 
McKenna (115), Thomson (180), Wheeler 
(191), Hohlbaum (88), Zeller (199), and 
Finochietto (64) have used pedunculated flaps 
of fascia. In general, good serviceable knees 
were secured; in two cases there occurred 
lateral motion and one case re-ankylosed. Of 
eighty-five cases on which Hohlbaum (88) 
reported, using free and pedunculated flaps, 
there were 78 per cent good results and 22 per 
cent poor. 

Steindler (174), Thomson (180), Brandstrup 
(21), Hessert (85), and Goddu (71) reported 
the use of free fascia flaps with good re- 
sults. 

Whitacre (192), Appel (6), Ogilvy (127), 
and Hoerhammer (92) secured good motion 
by the interposition of fascia and fat flaps. 




Fig. 47. Before mobilization. (Putti.) 

Kirschner (100) and Osgood (131) followed 
Payr's method, using free fascia flaps, but in 
Kirschner's cases adhesions formed, and Os- 
good's result was only fair and necessitated 
the wearing of a splint. Simon (171) and 
Schloffer (163), however, secured good re- 
sults by the same process. Tavernier (176) and 
Leriche (109) followed Putti's method. The 
former secured good motion, but Leriche's re- 
sult was an unserviceable leg. 

Flaps of tissue were tried by Hoke and 
Andrews (91) without success. Hofmann 




Fig. 48. 



Fig. 49- 



Fig. 48. After mobilization, showing weight bearing. 
(Putti.) 

Fig. 49. After mobilization, showing active extension. 
(Putti.) 



Fig. Si- 



Fig. 50. After mobilization, showing weight bearing. 
(Putti.) 
Fig. 51. Eighty-five degrees flexion. (Putti.) 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



29 







Fig. 52. Anteroposterior roentgenogram taken 27 
months after intervention. (Putti.) 



Fig. 53. Lateral roentgenogram taken 27 months after 
intervention. (Putti.) 



(87, b), by the use of free periosteal flaps, ob- 
tained only an active motion of 15 degrees. 
Fascia lata and strips of subcutaneous tissue 
were used by Verral (187). Roeren (157) se- 
cured immediate good results with the inter- 
position of flaps of fat, but the development of 
lateral motion made necessary the application 
of an apparatus. Cotton (39) secured a good 
result by the interposition of a muscle flap. 
Campbell (26, a) based his report on twenty- 
four knee-joint cases. In ten cases using 
fascia flap, one resulted in 40 degrees motion, 
one in 30 degrees, six re-ankylosed, and on one 
there has not been time to report. He used 
Baer's membrane in nine cases; in one he ob- 
tained practically perfect motion; in one, 70 
degrees of free motion; in four, the membrane 
extruded, and in two, of osteomyelitis, good 
results could not be expected. Two cases, in 
which free fascia from the thigh was inserted, 
were failures. In three operations in which 
prepatellar bursae were inserted, one resulted 
in 15 degrees flexion and voluntary extension, 
the second in 20 degrees flexion and voluntary 
extension; it was too early to report on the 
third case. Of twenty of the cases on which 
there has been sufficient time to record the 
end-results, thirteen had definite voluntary 
motion, four did not obtain motion of sufficient 



value, and three were not successful, as dense 
bone was involved. 

Campbell does not consider his work on the 
whole satisfactory. He recommends opera- 
tions for ankylosis of complete destruction of 
the articular surfaces and adjoining bone, and 
solid union of bony surfaces. In cases of com- 
plete fibrous ankylosis, irregular scattered 
bands, or irregular fibrous union with areas 
of destruction, operation is also advised. 

Up toi9i7,Baer(9,b)had reported twenty- 
eight cases of arthroplasties on knee joints. 
He obtained serviceable motion only in cases 
of fibrous ankylosis between femur and patella 
or femur and tibia, of which there were seven 
cases; four gave 75 degrees, 40 degrees, 50 
degrees, and 55 degrees of motion, respective- 
ly, and good function; three were failures — 
active tuberculosis set up. In five cases of 
bony ankylosis between patella and femur and 
fibrous ankylosis between tibiofemoral joint, 
excellent results were obtained. In sixteen 
cases of bony ankylosis between the patella 
and femur and femur and tibia, 19 per cent 
secured motion, 7 per cent had no ultimate 
motion, 6 per cent had 20 degrees, 2 per cent 
had 30 degrees, and 1 per cent, 45 degrees. 

In his early cases Baer made two lateral 
incisions, one on each side of the patella, 



3° 



SURGERY, GYNECOLOGY AND OBSTETRICS 



chiseled the bones apart, and modeled the 
ends of joint surfaces. The first piece of 
membrane was carried through the opening 
on one side of the patella to the other side. 
The second piece overlapped the first; the 
joint was covered as far as the top of the 
subquadriceps bursa. Baer later used the 
horseshoe incision. 

The writer believes that the general opinion 
is that lateral incisions do not give sufficient 
exposure to model the femur and tibia prop- 
erly. 

In 1920, Putti (145, f) reported on ten cases 
of knee arthroplasty. The largest range of 
motion obtained was 100 degrees, the smallest 
50 degrees, and the average 82 degrees. The 
average age was 22 years. Putti thinks 
arthroplasty of the knee should be executed 
more frequently, and that the restoration of 
the knee joint can give the greatest satis- 
faction to the patient. There is more than an 
aesthetic value obtained by these operations. 





Fig. 54 (at left). Ankylosis of the hip. Note flexion 
adduction, and inward rotation usually found in this con- 
dition untreated. 

Fig. 55. Ankylosis of the hip. Note proper position, 
i.e. abduction 10 degrees — slight flexion (10 degrees) and 
slight external rotation. 




Fig. 56. "Goblet" incision through the skin and fascia 
lata down to the muscles and trochanter. The lower tip 
of the upper flap is placed just below the trochanter. The 
downward prolongation lies along the outer surface of the 
femur. (Murphy.) 

Fig. 57. The flap of skin, fat, or fascia lata has been re- 
tracted upward; anterior and posterior borders of wound 



f o/w/« 



are retracted, exposing great trochanter with its attached 
muscles. The chain saw is passed on needle underneath 
superior muscle group, chiefly gluteus medius, down to 
capsule of joint, and trochanter with muscles attached is 
being sawed off in direction indicated by the dotted line. 
(Murphy.) 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



3i 




Fig. 58. The trochanter with its attached muscles is 
drawn upward, the anterior fibers of the gluteus medius 
muscle having been cut. The capsule of the joint is being 
incised at right angles to the direction of its fibers. In this 
operation it was not necessary to cut either the pyriformis 
or abdurator extemus muscles. (Murphy.) 



Fig. 59. The large gouge is being driven between the 
head of the femur and the acetabulum to divide the bony 
ankylosis between the two. A gouge has been selected 
the curve of which fits the normal curve of the head of 
the femur and the acetabulum, so that minimum amount of 
reshaping is necessary after division of ankylosis. (Murphy.,i 




Fig. 60. Reshaping and smoothing the head of the 
femur and the acetabular cavity with Murphy's end-mill 
and reamers. Head of the femur is dislocated backward 
from acetabulum preceding this step. (Murphy.) 



Fig. 61. Preparation from under surface of the skin-flap 
of the Murphy pedicled fascia and fat flap for interposition 
between the freshened ends of the bones. The dotted lines 
indicate the extent of the flap. (Murphy.) 



3 2 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 62. The interposing pedicled flap of fascia and fat 
has been passed around the gluteus medius muscle posterior 
to its attachment, and dropped down over the acetabulum, 
to the rim of which it has been sutured with chromicized 
catgut. The head of the femur, when replaced, will lie on 
this flap. (Murphy.) 

Putti uses the method set forth by Oilier of 
resecting the articulating surfaces, interposing 
membrane (Figs. 45 and 46), and preserving 
all the periarticular structures, particularly 
ligamentous. A modification of the Kocher 
incision is used; the cut is prolonged below to 
round the tibial tubercle (Fig. 42) . This allows 
rolling in the skin after the insertion of the 
patellar tendon has been removed with the 
tibial tubercle. A piece of bone 4 by 3 centi- 
meters and 1 centimeter deep is removed 
(Fig. 43) . Solid union of this afterward is very 
important. As there is sometimes difficulty in 
making this union, this constitutes the weak 
point of Kocher's incision. Putti also uses the 
procedure of plastic elongation by an incision 
in a Z-form of the quadriceps tendon to over- 
come strong contraction of the extensor ap- 
paratus. This incision gives good access to 
joint surfaces. 

The joint exposed (Fig. 44), the femur and 
tibia ends are shaped, the spine of the tibia 
made sharp, and the intercondyloid groove 



Fig. 63. The trochanter has been nailed back in place 
and the cut end of the muscles sutured. Usually Murphy 
used a continuous suture of phosphor bronze wire to re- 
unite the muscles. The skin is sutured with horsehair and 
two or three sutures of silkworm-gut are inserted, if nec- 
essary. (Murphy.) 

deepened. The transverse diameter of the 
condyles is preserved, but the sagittal diam- 
eter is decreased. In this way the loss of the 
crucial ligaments is compensated. The anky- 
losis is freed by a chisel to the posterior side. 
He uses manipulation to break up the bony 
lamellae, smooths resected surfaces by files, 
and removes any cicatricial mass. He advises 
against using patella flaps, as he found the 
patella nearly always increases in thickness. 
The patella should never be completely re- 
moved. The ligamentum patellae and tibial 
tubercle are nailed in place by a double-headed 
nail which is usually removed in a month. If 
necessary for flexion the quadriceps tendon is 
lengthened by the "Z" method. 

For 15 days the whole leg is in a plaster 
gutter splint in semi- flexion; 4 to 5 kilograms 
traction is applied. After the removal of the 
stitches, the knee is suspended to an overhead 
frame with strap and pulley. The amount of 
exercise depends on the patient's strength, 
ability to stand pain, and the reaction of the 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



33 




Fig. 64. Complete bony ankylosis of left hip with rota- 
tion of leg inward and abduction beyond pelvic inlet. 

(Murphy.) 



joint. With the patient on the edge of the 
bed, the limb hangs out and flexion is ob- 
tained by gravity. In a month, massage, 
faradism, heat, and mechanotherapy (Bon- 
net's apparatus) are used. Auto-immobiliza- 
tion is essential. In 6 weeks a stiff leg brace is 
applied. The patient should have good use of 
the limb in 3 months. 

Among his cases, Putti (145, d) reported one 
of complete bony ankylosis of the knee at an 
angle of 140 degrees. Suppurative arthritis 
had caused wounds to be open 5 months, and 
resulted in deep cicatrix. There was bony 
ankylosis between the femur and the tibia and 
between the femur and patella, and peri- 
articular ossification (Fig. 47). Putti used 
his regular technique in operation, prolong- 
ing Kocher's incision at the base to en- 
circle the tibial protuberance. One month 
after the operation there was 40 degrees 



motion, no pain, and complete extension. In 
5 months the patient could walk long dis- 
tances, had complete extension, and flexion to 
no degrees. There was slight lateral move- 
ment. In 7 months the flexion was 85 degrees 
and there was more lateral movement. The 
leg was serviceable. Fourteen months after 
the operation the patient returned to the 
hospital because of severe pain in the knee. 
The joint was flexed in the position of semi- 
flexion and could not be extended. After 
traction and hot air applications, the joint 
improved. The patient walked again, and 27 
months after the first intervention he could 
flex his knee to an angle of 85 degrees, had 
a movable patella, and no lateral mobility 
(Figs. 49, 50, 51, 52, and 53). 

HIP 

Ankylosis of the hip practically always is 
seen in the position of deformity; that is, 
flexion and adduction (Fig. 54). The correc- 
tion of this deformity results in a functional 
limb for working use (Fig. 55). It has, how- 
ever, a distinct disadvantage in sitting, stoop- 
ing, going up and down stairs, etc., as well as 
somewhat interfering with the gait. As the 
joint is rotary, it lends itself to arthroplastic 
measures. In single ankylosis, interference 
is decided upon with caution and judgment. 
In double ankylosis, the decision is easier. 

Any increase in motion in this joint im- 
proves the knee-joint action, and this, to- 
gether with the hypermobility of the lumbar 
spine, distinctly increases function. One must, 
however, remember that stability is very 
necessary, and unfortunate results, such as 
dislocation, have followed arthroplasty of the 
hip where stability has not been obtained. 

Ffoffa's (86) statistics in 1906 recorded three 
operations on the hip by Rochet and two by 
Nelaton, using muscle interposition. One of 
the five cases showed a mobility of 40 degrees 
in 1 year, the other a good function of 45 
degrees in 8 months. One case had good 
mobility at first, but it diminished later. The 
fourth case had good motion 5 years after the 
operation, and the fifth case resulted in poor 
function 9 months after intervention. 

Hoffa (86) reported one of his own cases 
in which he used a flap of fatty tissue. Seven- 



34 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Figs. 65, 66, and 67. One year after operation, showing that patient has a full normal range of 
motion. (Murphy.) 



teen months after the operation the patient 
walked, but active mobility was somewhat 
restricted. 

Stein (173), in 1907, in Bier's clinic, inter- 
posed a flap of the sartorius muscle in a case 
of double ankylosis of the hip. In 5 months 
there was 30 per cent of normal flexion, and 
extension and abduction of 10 per cent of 
normal. 

Ahrens (1), in 1908, used the gluteus maxi- 
mus muscle. The patient walked in eleven 
weeks. 

Meyer (117), in 1909, cited a case of using a 
flap of fatty tissue with a thin layer of muscle 
on a hip ankylosed from spondylitis. The 
thigh was flexed on the pelvis at 150 degrees. 
After the operation the patient had passive 
motion to 60 degrees, extension to normal, 
adduction 30 degrees, and abduction 45 de- 
grees. 

Duran (57), in 1910, used membrane, and 
he was able to obtain motion of 50 per cent 
of normal. 

Murphy (120, b) found that the hip joint 
gave him the best results in arthroplasty. He 
used three incisions; the original one was 
U-shaped, beginning 1.5 inches above the 
trochanter and 1 inch behind it, extending 
down 2 inches below and passing under and 
in front of it up to a point opposite the com- 
mencement. Sometimes the skin was divided 
down at the lowest point of the U to form the 
large interposed flap. The second incision was 
along the iliotrochanter line 1 inch below and 
in front of the trochanter and upward for 



about 5 inches in a straight line with the 
anterior superior spine of the ilium. The 
third was a modification of the second, in that 
the incision was curved and convexed back- 
ward behind the trochanter (Fig. 56). 

His next step was to free the trochanter by 
a chain saw and retract it upward with at- 
tached muscles (Figs. 57 and 58). 

The ankylosed head of the femur was sev- 
ered from the ilium, as near the anatomical 
line as possible, with a carpenter's and cabinet 
curved chisel (Fig. 59) . It was drawn oblique- 
ly into the acetabular cavity for 1 inch. The 
head was fractured out and a special globular 
burr fashioned the acetabular cavity. A cup- 
shaped well conformed the femoral head (Fig. 
60). 

A flap of fat and fascia, fascia lata, and 
subcutaneous fatty tissue (one-fourth inch 
thick) was inserted behind the head and neck 
of the femur, and the edge was sutured to the 
acetabular margin and to the capsular liga- 
ment with phosphor bronze wire (Figs. 61 and 
62). The head was replaced. The trochanter 
was nailed in place (Fig. 63). The fascia was 
re-approximated by chromic catgut and the 
skin sutured with silkworm or horsehair. No 
drainage was used. 

The field operated upon was dusted with 
bismuth subiodide powder and the wound 
sealed with gauze saturated with collodion. 
A pad of plain sterile gauze, moistened with 
95 per cent alcohol and 61 per cent phenol, 
was placed over the hip 4 or 5 inches beyond 
the line of incision on either side. A Rainey 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



35 




Fig. 68. Murphy instruments. 

travois splint and Buck's extension with 20 
to 25 pounds were applied. Both legs were 
dressed in an abducted position. 

Passive motion was instituted in 3 or 4 
weeks. 

In the majority of cases of ankylosis of the 
hip reported by Murphy, there resulted a 
good range of motion and ability to walk with- 
out support. Among them was one case of 
metastatic origin, of complete bony ankylosis 
of the left hip with rotation of the leg inward 
and adduction beyond the pelvic inlet (Fig. 
64) . The usual technique was followed in the 
operation. The patient made an excellent 
recovery. In 1 year she could walk without 
support and had full flexion (Figs. 65, 66, 67). 

Pettis (138) , Torrey (181) , Clark (36) ,Gibby, 
reported by McCurdy (113), Ceballos (30), 
Prando (142), Thomson (180), and Burlew 
(25) reported cases in which they had followed 
the technique of Murphy, using pedunculated 
flaps. Several good results were recorded. 
Thomson believes his case re-ankylosed be- 
cause he removed too little bone. 

McKenna (115) outlined his technique as a 
modification of the Murphy goblet-shaped in- 
cision. The cut was carried farther back to 
secure a fat and fascia flap that comes directly 
under the gluteus muscle. This fits into the 
acetabular cavity without cutting the pedicle 
of the flap. 



Perthes (136), in 1919, mobilized a hip joint 
ankylosed in the position of adduction. After 
the freeing of the ankylosis two pedunculated 
fat and fascia flaps were interposed. In spite 
of ankylosis of the other hip joint and of the 
two knees and of paralysis of the sciatic nerve, 
walking was possible. 

Baer (9,b), in 1917, reported his series of 
fifty cases of bony ankylosis of the hip in 
which an arthroplasty was done with the use 
of the chromicized pig's bladder. The result- 
ing motion in nine cases of gonorrhoea! 
arthritis was active motion in 89 per cent. 
Two cases operated on in 1909 resulted in 20 
degrees and 40 degrees motion, respectively. 
Infection was the cause of failure in one case ; 
in the other, the periarticular tissues needed 
stretching. In twenty-one cases of tubercular 
origin, 66 per cent good voluntary motion, 
utility and good walking ability were secured. 
One hundred per cent good serviceable motion 
resulted in fifteen cases of infectious arthritis. 
In five cases of arthritis deformans involving 
spine, hip, knees, and ankles, 60 per cent 
motion was obtained. 

Baer makes his incision from the anterior 
superior spine, down the thigh, parallel to the 
femur, between the tensor femoris muscle on 
the outer side and the sartorius on the inner. 
The capsule is stripped back, the ends of the 
bones shaped, and the membrane thrown 
around the femoral head. 

Baldwin (10), in 1915, reported a successful 
result, using Baer's membrane. 

Neff (122) used a U-incision with reflexion 
of the flap upward for the formation of a long, 
broad flap of fascia lata. If enough capsule 
was available, it was used for flaps; if not, 
fascia was interposed. 

In 1913, Osgood (131) reported on five 
cases; in one, using the capsule for a flap, the 
result was poor; in the second case, using 
tissue flap, the outcome was fair; in the third 
case of excision, death resulted; in the fourth 
case of fibrous ankylosis, in which free fascia 
was used, the result was good; and in the fifth 
case of fibrous type, doing a part excision 
according to Baer's method, the result was 
fair and improving. 

Two methods are used by Payr (134, b) on 
the hip. One consists of the separating of the 



36 



SURGERY, GYNECOLOGY AND OBSTETRICS 




X 



Fig. 69. U-shaped skin incision as Fig. 70. Line of fascia incision prepa- Fig. 71. Incision through capsule 

used by author. ratory to removal of great trochanter. parallel to and in center of femoralneck. 







\ 




- x 


A ^ss^JM^^ 






/ Mm* -- ibB^i 
















y t^^B| 






X^T 8 *"^ 




fipatlldt'*^ , 


•.--•■ / i' mt ~'K , • 


s 






Fig. 72. Separation of the femur 
from the acetabulum. 



Fig. 73. Reaming out of acetabulum 
and rounding of head with Murphy 
male and female rasps. 



Fig. 74. The fascia flap sewed around 
neck of femur with interrupted sutures 
and tied with a purse string. 



ankylosis, smoothing off of the head of the 
bone or building a new rounded epiphysis out 
of the neck of the femur, with interposition of 
fat (free or pedunculated) or a flap from the 
tractus ilio tibialis. The second process is the 
formation of a pseudoarthrosis as near as 
possible to the acetabular margin, likewise 
with the interposition of soft parts. Payr 
tries to form the pseudoarthrosis after the 
manner of a saddle joint, simulating the 
carpometacarpal joint. 

Corner (38), Steindler (174), and Hallopeau 
(76) reported the use of fascia lata in the hip. 
Corner and Steindler did not record their re- 
sults, but Hallopeau secured a good weight- 
bearing leg after operation for double bony 
ankylosis of 4 years' standing. 

Grange (74), in 1920, reported three cases 
of arthroplasty. In one, of bony ankylosis 
with internal rotation of the thigh, of trau- 
matic origin, a curved incision was made be- 
tween the crest of the ilium and the great 




Fig. 75. Reduction of femoral head. 

trochanter, the femur was divided at the neck 
and a flap of gluteus medius sutured over the 
raw end of the neck of the femur and a loose 
flap of fat from the buttock placed in the cup 
in the head of the femur. Within 2 months the 
patient could flex his hip to a right angle. 

Hohlbaum (88), in 192 1, reported twenty 
cases of hip ankylosis of tubercular, rheumatic, 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



37 




Fig. 76. 



Fig. 77- 



Fig. 76. Case 1. O. P. Roentgenogram of right hip be- 
fore arthroplasty. March, 1916. 

Fig. 77. Case 2. O. P. Roentgenogram of left hip before 
arthroplasty. March, 1916. 

gonorrhceal, arthritic, and other origins. Free 
fascia and pedunculated flaps were interposed. 
In his series there were six very good results; 




Fig. 80 (above). Case 1. O. P. Motion in right hip i l / 2 
years after arthroplasty. 

Fig. 81. Case 2. O. P. Motion in left hip i}4 years 
after arthroplasty. 



Fig. 78. 

Fig. 78. Case 1. O. P. 
years after arthroplasty. 

Fig. 79. Case 2. O. P. 
years after anthroplasty. 



Fig. 79. 
Roentgenogram of right hip 2 

Roentgenogram of left hip i}4 



five good results; six cases re-ankylosed; two 
patients died; and in one the result was 
unknown. 

Author's technique. In operation on the hip 
I use the following technique: 

The patient is given a very careful two-day 
preparation of the hip from the rib-line to 
below the knee. 

A skin incision is made beginning at the 
anterior superior spine and running in a hori- 
zontal plane to about 2 inches below the level 
of the trochanter, at which point it curves 
over the femur, 3 to 4 inches below the 
trochanter in a U-shaped fashion (Fig. 69). 
This flap, with considerable fatty issue at- 
tached, is elevated, raised to its base line, and 
retracted. 

A similar incision is made through the fascia 
external to the sartorius and sweeps around 
about 3 inches below the trochanter, at which 
point it reaches the base of the femur (Fig. 
70). The periosteum is separated downward 
one-half inch and then upward to the base of 
the trochanter. 

With a two-inch osteotome the entire 
trochanter is removed and elevated, taking 
with it all the muscle attachments. 

An incision is then made through the cap- 
sule beginning on the ilium and passing 
parallel to, and in the center of, the femoral 
neck to the base of the detached trochanter 
(Fig. 71). At the attachment of the capsule 



38 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 82. 



Fig. 83. 



Fig. 84. 



Fig. 8 S . 



Fig. 86. 



Fig. 82. Case 1. 0. P. Motion in right hip i>4 years 
after arthroplasty. 

Figs. 83 and 84. Cases 1 and 2. O. P. Lateral view, 
standing after arthroplasty. 

Fig. 85. Cases 1 and 2. O. P. Anteroposterior view, 
standing, after arthroplasty. 

to the femoral neck, it is cut off around on 
both sides for a distance of 1.5 inches and 
retracted. A blunt dissector then frees the 
capsule from the neck as much as it is possi- 
ble to free it. 

A study of the junction between the head 
and the ilium is made, and then with a curved 
chisel, covering a small space at a time, the 
femur is separated from the acetabulum. 
Care should be taken to follow the outline of 
the acetabulum, as this is always hard, while 
the head is usually atrophied (Fig. 72). 

Finally the head is freed and dislocated. 
With the Murphy male and female rasp (Fig. 
68), the acetabulum is thoroughly reamed out 
and the head is thoroughly rounded (Fig. 73). 
Great care should be taken to remove all 
spicules of bone. 

A piece of free fascia lata from the outer 
side of the opposite leg is removed and sewed 
around the neck of the femur by interrupted 
sutures. Then a purse-string suture is tied 
about it tightly (Fig. 74). 



Fig. 86. Case 2. 0. P. Motion in left hip ij^ years 
after anthroplasty. (Patient has about twice this motion 
but is handicapped in further flexion by double ankylosis 
of the knee. 



The head is reduced (Fig. 75). The old 
capsule is returned and sewed together and 
to the old attachments as nearly as possible. 
I feel that this very materially adds to stability 
and ensures against dislocation or a wabbly, 
unstable joint. 

The trochanter is then pulled down to its 
old position and held by resuture of the 
periosteum with fascia originally elevated. 
The skin is closed and the leg placed in plaster- 
of-Paris cast from the nipple line to the toe, 
with the leg in 10 degrees abduction, complete 
extension, and with a little pressure over the 
trochanter. 

The cast remains on 2^2 weeks and is then 
removed and traction applied. Passive mo- 
tions are started at the third week and should 
always be within the limits of pain. The 
patient is encouraged voluntarily to contract 
the thigh muscles and thereby get voluntary 
control early. 

The patient may walk with crutches in 6 
weeks and bear a little weight in about 8 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



39 



weeks. Convalescence as regards motion 
varies with the type of individual, but all 
motion should be within the pain limits. 

Case i. O. P., age 24. Patient had an ankylosis 
of 3 years' duration involving both hips and knees, 
due to an infectious process, probably neisserian in 
origin. (Figs. 76 and 77.) 

April 12, 1920. Arthroplasty of right hip by Dr. 
Andrew R. MacAusland, using the technique as out- 
lined. It was then about 3 years since the original 
infection. The operation was followed by some 
shock. The wound healed perfectly. A cast was 
applied. 

May 17, 1920. The cast was removed and passive 
movements encouraged. 

June 5, 1920. Patient out of bed with crutches. 

June 10, 1920. He walked with crutches. 

June 12, 1920. Discharged from hospital. 

January 13, 1923. No pain. Motion in flexion 40 
degrees. Motion in adduction and abduction in arc 
of 15 degrees to 20 degrees. (Figs. 78, 80, 82, 83, 
84, and 85.) 

Case 2. O. P., age 24. The previous history of 
this case was reported under Case 1. Both hips were 
ankylosed. (Figs. 76 and 77.) 

November 2, 1920. Seven months after the opera- 
tion on the right hip, Dr. Andrew R. MacAusland 
did an arthroplasty of the left hip, using the regular 
technique. 

November 29, 1920. The cast was removed. The 
wound healed by first intention. 

December 6, 1920. Passive motions were started. 

December 17, 1920. Patient was up in wheel- 
chair. He had some sensitiveness. Motion was 
omitted for 1 week. 

December 26, 1920. Passive motion renewed. 

January 4, 1921. He walked with crutches. 

January 22, 1921. He was discharged from 
hospital. 

January 12, 1923. No pain. Motion in flexion 40 
degrees. Good abduction and adduction. Excellent 
functional result. (Figs. 79, 86, 81, 83, 84 and 85.) 

JAW 

Ankylosis or greatly limited motion in the 
temporomaxillary articulations early assumes 
dangerous proportions, because of the inability 
of the patient to take nourishment. In young 
children this condition is complicated by the 
dangers from swelling during throat infections, 
so common in this type of case. Much of this 
infection undoubtedly arises from the inability 
to give proper hygienic care to the mouth and 
teeth. Arthroplasty is indicated in all of these 
cases, and, although the mortality is high in 
young children and the dangers of infection 
considerable, the relief is at times a matter 



of necessity. The method as described by 
Murphy has been accepted as standard. 

An incision is made in front of the ear from 
one-half inch below the root of the zygoma up 
to the hair line. The incision may be curved 
in, convexed backward, passing forward under 
the zygoma to 1 inch in front of the ear, 2 
inches above the zygoma. The L-incision gives 
the best access (Fig. 87). 

The ankylosis is divided and a flap of 
temporomaxillary muscle aponeurosis dropped 
over the zygoma. (Figs. 88, 89, 90, 91, and 92.) 

Murphy (120, b), in 1913, brought to our at- 
tention his series of nine arthroplasties of the 
jaw, seven for bony ankylosis and two for 
extra-articular fibrous fixation. The first case, 
of a boy with fibrous ankylosis of the left 
temporomandibular joint and bony ankylosis 
of the right, resulted in the ability to open his 
mouth 1 inch, 4 weeks after the operation. 
Now he can put an apple between his teeth. 
An operation on a case of fibrous ankylosis 
allowed the opening of the jaws to 1.5 inches 
3 months after the operation. 

Another patient who had fibrous ankylosis 
could open his mouth 1 inch in 5 weeks after 
the operation. 

As the impairment of health is involved in 
an ankylosed jaw, early attempts at operation 
were made. 

Hoff a (86) collected eighteen cases : Helf er- 
ich one, Lentz one, Mikulicz one, Henle one, 
Bilczynski one, Kusnetsoff one, Gluck two, 
Rochet four, Schmidt one, Foederl one, Orlow 
two, Meyer one, and Beresowski one. In 
thirteen cases in which muscle flaps were used, 
good results were secured, and the average 
separation of the incisor teeth in ten cases 
was 2.6 centimeters. Good results were ob- 
tained in two cases using skin flaps. In one, 
inserting hog's bladder, the incisors were 
separated 2.6 centimeters, and in two cases, 
using gilded plates, 2 and 1.75 centimeters. 

Hoff a (86) reported two of his own cases; 
one of simple resection resulted in a separation 
of 2 centimeters and the other, using a tempo- 
ral muscle flap, allowed the placing of two 
fingers between the jaws. 

Biermann (16), in 1909, reported using a 
flap of the temporal muscle and obtaining a 
good result. 



40 



SURGERY, GYNECOLOGY AND OBSTETRICS 



M 




Fig. 87 (at left). L-shaped skin incision above the 
zygoma and in front of the ear, so placed to avoid injury 
to the facial nerve. (Murphy.) 

Fig. 88. Skin flap retracted and zygoma and neck of 




mandible exposed. Two curved periosteal elevators are 
shown closely applied to the posterior surface of the neck 
of the mandible, thus protecting the internal maxillary 
artery from injury during division of the bone. (Murphy.) 



Stein (173), in the same year, obtained a 
perfect recovery of a case using muscle flaps. 

Baer (9, b), in 191 7, recorded his series of 
nine cases in which eleven operations on 
temporomaxillary jaws had been done. One 
excellent result was secured in which a boy 
had even more motion than normal. The 
other cases showed good results. In Case 8, 
the patient could open his mouth only 3 
centimeters; this case had been operated on 
twice by other methods and had been anky- 
losed 23 years. 

An arthroplasty on another case of marked 
cicatricial changes allowed the opening of the 
mouth to the extent of 0.5 centimeter. A 
baby, 18 months old and in weakened con- 
dition, died from the effects of the operation. 

Baer, in his technique, first scrubs the place 
of operation, using potassium permanganate, 
oxide, and bichloride of mercury, ether, and 
alcohol. The incision is made parallel to the 
zygoma and along its lowest border; the fibers 
of the external pterygoid muscle are separated 
and the temporal muscle retracted forward. 
He then cuts through the periosteum of the 
ramus of the inferior maxillary bone and ex- 
poses the condyle. This is separated from the 



ramus and the temporal bone. The bones are 
shaped and a cuff of membrane sewed to the 
periosteum of the bone. The muscle is brought 
together and sewed, and the wound is closed. 
After 2 weeks the patient is encouraged to use 
his mouth, and movements are regulated by 
graduated corks. 

An arthroplasty, using Baer's membrane, 
was reported by Osgood (131), in 1911, for 
complete bony ankylosis of the jaws of 2 years' 
duration. A slight pus discharge made 
necessary an incision and the removal of the 
membrane. Four months after the inter- 
vention the motion was good. 

Neff (122) used a curved incision beginning 
in front of the tragus and carried up over the 
zygoma. Fascia was stripped from the zygoma 
subperiosteally. The condyle was separated 
from the glenoid fossa and the joint mobilized. 
A flap from the temporal fascia or masseter 
was sutured to the capsule on the inside. 

Putti (145, a), in 1913, reported three jaw 
arthroplasties. In operation, he used Abbe's 
incision, resected enough bone to allow open- 
ing the jaw and interposed a free flap of 
fascia lata 6 by 8 centimeters, taken from the 
base of the great trochanter. In the post- 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



41 




Fig. 89. Dividing the neck of the mandible with the 
Gigli saw. In actual operation the saw is not allowed to 
make so acute an angle as shown in the illustration, because 
of its great tendency to break when sharply bent. (Murphy. ) 

Fig. 90. The neck of the mandible has been divided, the 

operative treatment, the passive exercises are 
regulated by means of wooden wedges. 

Four months after intervention in the first 
case of total bilateral ankylosis of blennorrhceal 
origin, the patient had nearly normal motion. 
The after-treatment had been neglected, which 
accounted for lack of complete mobility. In 
1 month after operation in the second case of 
complete congenital ankylosis of the right 
temporal jaw, the child could open his mouth 
to allow a space of 2.5 centimeters between 
the incisors. The third case, one of complete 
ankylosis between the condyle and glenoid on 
the left side, showed in 1 year the ability to 
open the mouth fully. 

Blair (18), in 1914, found a flap of sub- 
cutaneous temporal fascia admirably adapted 
for interposition. His incision was almost 
completely within the hair line. Enough bone 
was removed to leave a space 0.5 inch wide. 
The immediate result was 0.75 to 1 inch open- 
ing, and this, by the use of a rubber bottle- 
stopper, was increased further. 



cut ends of the bone separated by traction on the lower 
fragment and space thus provided for the interposing 
fascia and fat flap. The curved periosteal elevators still 
protect the internal maxillary artery from trauma. (Mur- 
phy.) 

Carr (28), in 191 7, obtained three good re- 
sults, using a modification of the Murphy 
method. He was unacquainted with the 
Murphy process at the time, but he would use 
it on future cases. In 18 months one patient, 
who had had complete fixation for years, could 
separate his teeth 1.25 inches. The second 
patient, in 3 weeks, could open and close his 
mouth without discomfort, and the third 
patient could eat in 3 days, as the muscles 
had not been greatly contracted. 

The same year Prando (142) applied the 
Murphy method in a case. Although it be- 
came gangrenous, the case turned out well and 
the patient can open his mouth and talk 
clearly. 

Henderson and New (81), in 191 8, tabulated 
twenty-three cases of ankylosis of the lower 
jaw operated on in the Mayo Clinic during a 
period of 8 years. They divided the ankylosis 
into articular, extra-articular, and articular- 
extra-articular types, depending on the loca- 
tion of the fixation. Fifteen cases were articu- 



42 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 91. The pedicled fascia and fat flap is dissected 
from temporal fascia and free end of flap is turned inward 
between divided ends of mandible and sutured securely 
in place with tacking stitches. (Murphy.) 

lar, five extra-articular, and the remainder 
articular-extra- articular. The average age of 
the patients was under 10 years. Excision was 
the basic principle of each operation, and no 
interposing substance was used. 

The fifteen cases did well, and from 1 inch 
to 1.75 inches separation was obtained. In the 
extra-articular types the best results were 
secured by forcible stretching. In the articu- 
lar-extra-articular type the scarring of the 
muscles prevented wide separation, but all the 
patients secured an opening of an inch. 

Douglas (54), in 1919, operated for com- 
plete bony ankylosis of the left temporo- 
maxillary joint. A horizontal incision was 
made just above the zygoma, the bones were 
separated and a flap of the temporal fascia 
with overlying fat interposed. The final result 
was excellent, although after-treatment was 
not carried out. 

Woolsey (198) also did a similar operation 
and obtained a good result. He kept the jaws 
apart for some time after the operation. 

Kerr (99), in 1920, cited four successful 



Fig. 92. The flap is now in place and the wound ready 
for closure. (Murphy.) 



cases. One patient could open his mouth one- 
sixth inch and the second one-fourth inch. A 
curved, L-shaped incision was made, begin- 
ning 2 inches above and 0.5 inch in front of 
the ear and down to the external auditory 
opening, then anteriorly for 1.5 inches. The 
facial nerve was avoided. The condyle of 
the mandible was sawed off with a chain saw 
and a flap of temporal muscle inserted. Both 
patients can masticate normally. The third 
patient, suffering from fibrous and bony an- 
kylosis of both joints of the mandible, with 
contractions of the periarticular muscles and 
fascia, after operation could masticate solid 
food. He had to guard against muscle contrac- 
tions. Fourth patient after operation could 
open her mouth normally and masticate food. 
Ritchie (152), in 1920, emphasized the im- 
portance of the after-treatment in the form of 
continual motion during waking hours, and 
wearing a rubber gag at night. He reported 
two cases using flaps of temporal muscle. In 
one case the flap was cut too short and pulled 
off when applied as a free flap. It was ex- 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



43 



truded on the fifth day. In the other case the 
flap was cut large enough. The end-results of 
both cases were equally complete. 

Chubb (34), in 1920, reported a method 
which he had found very successful. He di- 
vided the operation for ankylosis of the jaw 
into two groups according as the bone is 
resected from the region of the condyle or 
from the horizontal ramus. 

The bony or fibrous ankylosis in the five 
cases he described was between the anterior 
border of the coronoid and the pterygoid 
aspect of the maxilla. Four cases were trau- 
matic. One was infective in origin, and fol- 
lowed a bilateral suppurative arthritis of the 
temporomandibular joints in infancy. 

In operation, the incision started in the pre- 
auricular fold at the lower level of the ex- 
ternal auditory meatus, passing vertically up- 
ward to the level of the tip of the pinna, and 
curving forward below the superior temporal 
crest to terminate anteriorly within the hair 
region. The zygoma was exposed and the 
necessary bone removed piecemeal. The 
whole coronoid process was removed. 

In the case of infective origin of 15 years' 
standing, the condylar neck region and cor- 
onoid of the left and right sides were resected. 
The operation was completed by a flap of 
temporal fascia and muscle. 

The result in all cases was a gap of at least 
2.5 centimeters and a very satisfactory power 
of mastication. 

Imbert (95), in 192 1, emphasized regulating 
the dimensions of the incisions for ankylosis 
of the jaw by the crossing of the facial nerve 
on the neck of the condyle. The upper ex- 
tremity of the incision should be about 2 
centimeters above the most prominent part of 
the tragus. The resection of the condyle is 
made by means of scissors and is at least 0.5 
centimeter in height. He recommended the 
interposition of soft parts. 

Dufourmentel and Darcissa (55), in 192 1, 
presented two cases. In one, of complete 
temporomaxillary ankylosis of gonococcic 
origin, the thickness of bone was destroyed 
and a piece of rubber inserted. Their special 
apparatus was used in the after-treatment. 
Three months after the operation, the power 
and amplitude of the jaw was normal. A 



second case, using a muscular aponeurotic 
flap, failed; resection, with no interposition of 
rubber, resulted in a normal joint. 

Bockenheimer (19), in 1922, used an in- 
cision behind the ear in freeing bony ankylosis 
of the jaw, of inflammatory origin. After re- 
section, a flap of fat and fascia was interposed. 
In 15 months the patient could open her 
mouth normally. This incision had the ad- 
vantage of avoiding the facial nerve and of 
hiding the scars. 

Gilpatrick (69) recently (1922) reported a 
severe case of ankylosis of the jaw very similar 
to a case reported by Murphy. The patient 
had had almost complete ankylosis of the 
inferior maxilla for 14 years as a result of 
scarlet fever, complicated by an infection of 
both mastoids. The food had to be macerated 
in the plate and the boy could talk only 
through clenched teeth. 

The right side was attacked first in operation . 
An incision 1.5 inches long was made in front 
of the right ear from a point 0.5 inch below the 
zygoma upward. All new bone was removed. 
The jaw could then be opened so that the left 
side was not touched. A flap of fat and fascia 
from the skin anterior to the original incision 
was interposed. In 10 days the patient could 
eat. 

SHOULDER 

The shoulder joint is rarely the seat of 
troublesome ankylosis. The mobility of the 
scapula replaces the lost motion, especially 
when ankylosis has occurred in the position 
of election; that is, abduction of 50 degrees to 
70 degrees and flexion of about 15 degrees to 
20 degrees forward of the frontal plane, in 
which position the shoulder function closely 
simulates normal. (Figs. 93 and 94.) 

No arthroplastic measure can be considered 
in the absence of the deltoid muscle. 

The first arthroplasty of the shoulder was 
reported by Nelaton (123), in 1903. The 
operation was done by Caville. A four-inch 
incision was made below the clavicle, passing 
externally to the coracoid process, down along 
the arm following the fibers of the deltoid. 
The head of the humerus was divided at the 
level of the anatomical neck. A piece of del- 
toid obtained by a transverse section was inter- 
posed between the surface of the humerus and 



44 



SURGERY, GYNECOLOGY AND OBSTETRICS 





Fig. 93 (at left). Ankylosis of shoulder. Position of rest; note rotation of scapula 
with full rest position of arm. 

Fig. 94. Ankylosis of shoulder. Full abduction obtained by rotation of scapula. 



the glenoid cavity. A counter-incision was 
made at the same level and a thread passed 
through the opening, surrounding in loop 
form the extremity of the muscular strip. By 
tightening, the muscle was applied in the 
articular cavity. The result was good; there 
was passive motion in 3 days. The patient 
can sew. Abduction is limited. 

Hofmann (87, b), in 1908, used periosteal 
transplants rom the tibia. The results were 
excellent ; 1 year after the operation the rotary 
movements were almost normal. There was 
active abduction with fixed scapula up to 45 
degrees, after which the scapula moved with 
the arm. 

Ochsner (125), always conservative in ad- 
vising arthroplasties in ankylosis with de- 
formity, makes a vertical incision over the 
middle of the deltoid muscle, and separates 
the fibers by the Kocher dissector. A vertical 
incision is made in the capsule to expose the 
head of the humerus. This is severed by cut- 
ting the neck with a chain saw. Strands of 
silkworm gut are inserted for drainage. The 
arm is bandaged snugly to the side and the 
forearm placed in a sling. He has not found 
it necessary to use a fascial flap. All of his 
patients, within a few months, have been able 
to use the arm as before ankylosis; they can 
comb their hair, etc. 

In the treatment of ankylosis without de- 
formity, in the finger, ankle, shoulder joint, or 
wrist, Ochsner does not consider arthroplasty 
indicated. In the knee, elbow, and hip, the 
subject is debatable. On the knee, he uses the 
resection method; on the hip, subtrochanteric 
osteotomy; and on the elbow, force only. He 
commends the Murphy method. 



Neff (122) believed that operation in the 
shoulder is rarely indicated, as the scapular 
muscles provide good function. In case of 
intervention he advised reaching the joint 
through an incision 3.5 inches long, extending 
from the base of the coracoid and on a level 
with it, down on a line with the bicipital 
groove. The cephalic vein serves as a guide. 
The greater tuberosity is divided by means of 
a Gigli saw and retracted upward. The re- 
mainder of the operation is like that on the 
hip. Fascia or capsule may be used as flaps. 

Murphy (120, e) did not report an arthro- 
plasty of the shoulder, but in 19 13 he outlined 
his technique on the cadaver as follows: The 
skin and deltoid are split and the fascia 
separated along the anterior margin for 4 
inches. It is then elevated to expose the 
coracoid process with the head of the biceps 
and coracobrachialis. The process is divided 
three-fourths inch from the tip and displaced 
outward. The ankylosis is chiseled between 
the glenoid fossa and the head of the humerus, 
and an additional excavation of the glenoid 
fossa made. An incision at a right angle to 
the original incision is made across the chest, 
over the middle pectoralis major muscle. A 
flap of fat, aponeurosis, and pedunculated 
muscle is placed between the head of the 
humerus and the glenoid fossa. The anterior 
portion of the deltoid may also be used as a 
flap. 

W. L. and C. P. Brown (23), in 1914, re- 
ported the use of a portion of the short head 
of the biceps for the interposed flap. It is 
located correctly anatomically and covered 
with a tendinous sheath; its attachment to the 
coracoid process gives the pedicle the right 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



45 




Fig. 95 (at left). Ankylosis of wrist. Position of weakness 
(flexion) ; note compensatory contraction of phalanges. 

Fig. 96. Ankylosis of wrist. In position of strength, a most 
important factor in all wrist cases. 




location. An incision in the shape of a re- 
versed "S" is made from the junction of the 
middle and outer thirds of the clavicle, for- 
ward and downward below the acromion 
process. The muscle fibers of the sulcus should 
be separated, coming down directly on the 
tendinous attachment of the inner head of the 
biceps. The tendon of the pectoralis major 
should be transfixed with a linen thread and 
then cut loose from the humerus; the attach- 
ment of the inner fibers of the deltoid is trans- 
fixed and severed from the humerus, which 
will facilitate its retraction. The forefinger of 
the left hand is passed beneath the inner head 
of the biceps, separating it from the coraco- 
brachialis and then its sheath and fibers cut 
across 4.5 inches below its attachment at the 
glenoid cavity. About one-half the muscle, 
of fan-shape, 4.5 by 3.5 inches, is taken. The 
capsule of the joint is opened and the head of 
the humerus is separated from the glenoid 
fossa, preserving the head of the biceps if 
possible. Enough capsule is removed to 
mobilize the joint. The flap is drawn in place 
by three No. 1 chromicized catgut sutures, 
guided by the finger. If the capsule allows 
good motion, it should be sutured; otherwise, 
it should be free. If the pectoralis major has 
contracted, it should not be re-attached to the 
humerus unless it is lengthened. 

The arm is put in a cast at right angles to 
the body with the forearm flexed, if the head 
of the biceps is severed. The cast is removed 
in 10 days. 



The case of infectious origin on which the 
operation was done resulted in perfect motion. 
The patient, a carpenter, resumed his trade in 
6 weeks. There was some restriction of the 
arc of motion because of periarticular con- 
traction, but 2 years after intervention the 
patient had practically recovered the arc of 
motion. 

Ringel (151) demonstrated a case, in which 
there had been a complete shattering of the 
shoulder region, treated by freeing of the 
joint and interposing a pedunculated muscle 
flap from the deltoid. The immediate result 
was so good that the patient returned to the 
army. Later it was found that the flap had 
sloughed and new bone formed. In the second 
operation, a broad fat and fascia flap from the 
thigh was fixed over the humerus. Free 
motion in all directions was obtained; the arc 
of motion was limited because of the great 
atrophy of the deltoid. 

Thomson (180) reported a case in 191 7. He 
made an anterior incision, removed the greater 
part of the head of the humerus and stitched 
in a piece of fascia lata from the thigh. The 
limb was put in the position of right angle 
abduction. A sufficient range of movement 
was secured. 

Verrall (187) believes he was justified in 
operating on a shoulder adducted and having 
a small degree of painful motion, as he did 
not jeopardize arthrodesis in a good position. 
He exposed the joint along the anterior border 
of the deltoid and dislocated the humerus 



4 6 



SURGERY, GYNECOLOGY AND OBSTETRICS 



through the wound. The glenoid was hollowed 
into shape and three-fourths of the humerus 
removed. A flap of subcutaneous tissue from 
over the deltoid was turned over the glenoid. 
He does not report his result. 

Grange (74), in 1920, did an arthroplasty 
for ankylosis of the shoulder joint in a slightly 
abducted position with a good deal of destruc- 
tion of the head and great tuberosity. In the 
operation, an incision was made along the 
lower border of the clavicle and down the 
front of the arm for 3 inches; another was 
made just below the acromion process to meet 
the first, and a third was made along the lower 
border of the pectoralis major. This was 
divided where it crosses the axilla, and the 
anterior half of the deltoid was cut through 
0.5 inch below the acromion process, and 
turned down. The short head of the biceps 
and coracobrachialis were then divided. The 
humerus was exposed and rounded, and a 
large flap of superficial fascia turned in from 
the surface of the pectoralis major. The 
wound was closed and the arm put up with 
the shoulder abducted 45 degrees. Active ab- 
duction to 45 degrees, flexion to 45, and 60 
degrees rotation resulted. Passive abduction 
and flexion could be obtained to 90 degrees. 

WRIST 

For most purposes, a wrist ankylosed in 
hyperextension permits satisfactory function 
with undiminished strength in the fingers. 
(Figs. 95 and 96.) Occasionally, however, 
lateral and flexed motions are desirable, in 
which case mobilization may be attempted. 

Only a few cases of arthroplasties of the 
wrist have been reported. 

Hoffa (86) records a case done by Nelaton 
and Ombredanne (124) in 1905. They resected 
the first row of carpal bones and interposed a 
tendon-muscular flap . The outcome was poor ; 
ankylosis recurred in four months. 

Hoffa (86), himself, did two wrist arthro- 
plasties. In one he inserted a magnesium 
plate. A fistula resulted, which necessitated 
the removal of the plate; ankylosis recurred. 
In the other operation he resected the first row 
of carpal bones and inserted a fat and fascia 
flap taken from the proximal side of the wound. 
Two months after the operation, there was 




Fig. 97 (above). Case i. E.M. Lateral roentgenogram 
showing ankylosis before arthroplasty. 

Fig. 98. Case 1. E.M. Anteroposterior roentgenogram 
showing ankylosis before arthroplasty. 

free motion of several degrees. Nine months 
later there was good mobility in the wrist and 
excellent function. 

Stein (173), in 1907, in Bier's clinic, did an 
arch-shaped resection of the bones and inter- 
posed a muscle flap. In 2 years the passive 
motion was good, but the function was un- 
satisfactory, due to the patient's cutting the 
flexor tendons. 

Baer (9, c), in 1909, reported a case of con- 
genital union between the head of the radius 
and the ulna. Chromicized pig's bladder was 
interposed. Three months after the opera- 
tion, supination was possible to 100 degrees, 
but a twist in the radius prevented it going 
farther. 

Two more cases were cited by Baer (9, a) in 
19 18. One of congenital synostosis of the 
radial head and ulna, in which the animal 
membrane was used, gave voluntary motion 
of no degrees. Marked curvature of the 
radius made normal conditions impossible. 
The other case of bony ankylosis between the 
ulna and radius, when chiseled apart, gave 90 
degrees supination and pronation. 

L. Duran (57), in 1910, did an arthroplasty, 
using Baer's membrane. Painless mobility of 
about 50 per cent of normal resulted in 1 month . 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



47 






Figs. 99 and ioo. Case i. 
arthroplasty. 



E. M. Ankylosis before 



Mention has been made of an arthroplasty 
by Whitman (193) in 191 1, in which a section 
representing the first row of carpal bones was 
removed and the deformity corrected. The 
record is incomplete. 

Neff (122), in 1912, outlined his technique 
of operation on the wrist: A convex incision 
with the convexity downward through the 
skin, on the dorsum of the wrist, extending 
from the ulnar to the radial side; division of 
the posterior annular ligament and retraction 
of the extensor tendons laterally; division of 
the capsule transversely, low down on the 
carpal bones and dissection of it upward, 
leaving it attached to the radius and ulna; 
resection of the first row of carpal bones in an 
arched direction with convexity upward; in- 
version of the posterior capsular flap between 
the articular surfaces. If there is not sufficient 
capsule a fascia lata flap or rectus aponeurosis 
may be used. The wound is sutured, and 
passive and active motion and massage begun 
on the eighth day. 

Murphy (120, f), in 1913, reported three 
wrist arthroplasties. In one, of infection, an 
incision was made over the end of the radius 
on the back of the arm, and a flap of super- 
ficial fat and fascia interposed between the 



Fig. 101 (above). Case i. E. M. Anteroposterior 
roentgenogram after manipulation. (MacAusland.) 

Fig. 102. Case i. E. M. Lateral roentgenogram after 
manipulation. (MacAusland.) 

radius and the scaphoid. Limited motion re- 
sulted; ankylosis did not recur. The second 
case was that of a woman who had multiple 
arthritis of 6 years' duration. Elbows, ankles, 
knees, and hips were involved. On one wrist 
he made a longitudinal incision over the ulnar 
styloid process, dissected down on the ulna, 
and with an elevator separated the muscles, 
tendons, and arteries. Care was taken not to 
dissect the periosteum from the bones. A 
pedicled ulnar flap from the outer surface of 
the wrist was passed over the ends of the 
bones, and the tip was brought to the radial 
side of the joint, where it was fastened. A 
radial flap was interposed in like manner. The 
arm was dressed in slight anterior flexion and 
held in an elevated position. 

Five weeks later, Murphy operated on the 
other wrist, the carpal bones and ulna and 
radius of which were completely ankylosed. 
Only a radial incision was made. The lower 
ends of the ulna and radius were resected about 
five-eighths inch to three-fourths inch. The 
division of the ankylosis was semicircular with 
concavity upward. A flap from the dorsum of 
the radial side of the forearm was interposed 
and fastened to the joint capsule on the ulnar 
side. 



4 8 



SURGERY, GYNECOLOGY AND OBSTETRICS 




M '--A v. 



£t>o»K>'»vJ 3e l 



Fig. 103. Line of incision used 
in author's technique. 



(^•f>G<t/clinr>' 






Fig. 104. Cutting out the joint line Fig. 105. Making convex and concave 

with curved chisel and removal of a surfaces smooth with file, 
small amount of bone. 



The right wrist had an almost normal con- 
formation; the left wrist luxated slightly. 

In 1922 I did an arthroplasty in the follow- 
ing case: 

Case i. E. M. On May 12, 1922, patient fell 
through a pane of glass, cutting the right wrist. This 
was followed by infection, resulting in ankylosis in 
deformity of 25 degrees flexion. Scars from numerous 
incisions during sepsis were present. 

When I first saw the patient, he had power in all 
tendon groups, but was unable to make a fist, and 
the wrist was ankylosed in 25 degrees flexion de- 
formity. Roentgenograms showed considerable 
atrophy and periarthritic changes with some 
posterior displacement of the tip of the ulna (Figs. 
97 and 98). Manipulation into the hyperextended 
position was done in August, 1922, and a plaster 
applied. 

August 23, 1922. Patient could bend fingers. Use 
encouraged while in plaster. 

September 25, 1922. Plaster cast removed and 
hyper extension splint applied. Baking and massage 
daily. Wrist in good position and, although motion 
of fingers had increased and the wrist was in hyper- 
extended position, there was no wrist-joint motion 
(Figs. 99 and 100). 

October 30, 1922. Roentgenogram shows anky- 
losis between the scaphoid, semilunar, and the end of 
the radius (Figs. 101 and 102). Arthroplasty of the 
wrist was advised. 

November 7, 1922. Operation. 



Operative technique — author 's method. Poste- 
rior incision 5 inches long (Fig. 103). Skin and 
superficial fascia clamped off with towels. In- 
cision then made over fascia and posterior 
ligament and both retracted. Common ex- 
tensors retracted outward, and the extensors 
of the thumb were retracted inward. An 
incision was then made over the capsule of 
the old joint, which was carefully saved and 
retracted laterally. With a curved chisel the 
scaphoid and semilunar were separated by 
osteotomy from the radius. The lower end of 
the radius was re-shaped and made to ap- 
proximate as near as possible the normal radial 
end. One-fourth inch of the carpus was re- 
moved and the carpus very carefully rounded 
to conform to the opposing radial end (Figs. 
104 and 105). A piece of fascia was then re- 
moved from the outer side of the lower thigh 
of the right leg and sewed between these 
surfaces with interrupted chromic gut. It 
was sutured first to the anterior capsule of the 
joint, then to the posterior capsule, well over 
the head of the radius (Figs. 106 and 107). 
The old capsule of the joint was then closed 
with interrupted chromic catgut and the skin 
was closed with continuous catgut. The hand 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



49 




Fig. 106 (at left). Suture of fascia lata to anterior capsule. 
Fig. 107. Suture of fascia lata to posterior capsule. 



was placed in a cast in hyperextension. The 
plaster was allowed to remain on 3 weeks and 
then was split down the side and gentle 
passive motions begun (Figs. 108 and 109). 
Active motions were encouraged. 

November 20, 1922. Treatment continued. There 
was no discharge. An X-ray showed separation be- 
tween carpus and radius as a result of arthroplasty 
(Figs, no and in). 

November 27, 1922. Hand was in good condition. 
No pain, and use of the fingers had increased. 
Hyperextension splint applied. To have daily baking 
and massage with motion. 

January 22, 1923. There was 10 degrees lateral 
motion in the wrist, hand flexion 5 degrees, hyper- 
extension 35 degrees to 40 degrees (Figs. 112 and 
113). The patient could almost make a fist. His 
inability completely to close fingers was due to the 
old sepsis involving the sheaths of the tendons. He 
has no pain and wishes to go to work. 

I feel that the function will increase as time goes 
on. 

FINGERS 

Unfortunately, the phalangeal joints lend 
themselves poorly to plastic work, due to the 
fact that, in most cases, the injury which 
causes the ankylosis also damages the tendon 
sheaths and the tendons. As a result rapid 
and extensive atrophy follows, rendering the 
skin and subcutaneous tissue very delicate. 



So tender are all the structures with which the 
operator comes in contact that, even though 
he uses the best technique, he is baffled. Not 
until the metacarpal row is reached can the 
operator feel that the chances of success favor 
plastic work, and here only in the presence of 
intact tendons and sheaths. 

In 1908, Hofmann (87, b) reported a case of 
fibrous ankylosis of two interphalangeal joints 
of the same hand, in which he interposed 
periosteal transplants from the tibia. Six 
weeks after the operation there was good 
passive but no active mobility. 

Eloesser (60) secured a good result by im- 
planting a finger joint from the cadaver. 

Goebell (72) also obtained a good movable 
joint by implanting a toe joint in a finger re- 
sected for severe arthritis deformans. 

Hammesfahr (78), in 191 2, reported trans- 
planting the joint of the second toe with capsule 
and ligaments between the proximal phalanx 
of the middle hand bone. The result has been 
very satisfactory; the patient can move the 
joint freely in all directions; there is only 
slight lack of bending ability. 

In 1922, Oehlecker (126) reported good 
results, after 6 years, in transplanting the 
entire finger joints taken from the patients 



So 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 108. Fig. 109. 

Fig. 108. Case 1. E. M. Lateral roentgenogram 2 months 
after arthroplasty. 

Fig. 109. Case 1. E. M. Anteroposterior roentgenogram 
2 months after arthroplasty. 

themselves and from other persons. The re- 
sults in the autoplastic cases were the better. 

Roepke (156), in 1913, operated for finger- 
joint ankylosis and mentioned that he had 
success with free fat transplantation. 

Payr (134, b), in 1914, recommended arthro- 
plasty of the fingers, using pedunculated im- 
plants of flaps of tendon sheath from the 
palmar side of the hand. He reported two 
arthroplasties of the interphalangeal joints 
with favorable results. 

Gallagher (67), in 191 5, reported the result 
of an arthroplasty for traumatic bony anky- 
losis of a proximal interphalangeal joint of the 
fourth finger. He does not describe his method. 
In 2 months the patient could lift and carry on 
the joint 7.75 pounds. There was voluntary 
flexion to about 45 degrees and extension to 
about 170 degrees. He has devised a simple 
apparatus to give proper exercise to the joint. 

Hamilton (77) reported success in arthro- 
plasties on the phalangeal and metacarpo- 
phalangeal joints. The same principles are in- 
volved as in arthroplasty on the larger joints. 
The incision for all phalangeal joints is made 
parallel to the long axis of the finger. A mid- 
lateral incision is made on either side down to 



Fig. no. 
Fig. no. Case 1. 



Fig. in. 
E. M. Roentgenogram after arthro- 



plasty. (In plaster.) 

Fig. in. Case 1. E. M. Roentgenogram after arthro- 
plasty. (In plaster.) 

the capsular ligament. For metacarpo- 
phalangeal joints an incision is made at the 
junction of the posterior and lateral surfaces 
on either side. The bones are mobilized by 
sawing two nicks about one-sixth inch apart. 
All fragments of capsular ligament are re- 
moved. In the thumb he recommends the use 
of a free flap. Extension is applied by means 
of a splint and adhesive plaster. Passive 
motion is instituted after 2 or 3 weeks. A case 
is cited of virulent polyarthritis which left a 
man with bony ankylosis of the thumb joint 
and proximal phalangeal joint of the index 
finger of the right hand. Within 6 months 
after arthroplasty the patient was accepted as 
a naval recruit by the United States Navy. 

Verral (187), in 1920, reported his belief 
that the proximal joints can be treated by 
arthroplasty, using free fascial graft. Meta- 
carpophalangeal joints afford a good field; for 
the first, second, and fifth fingers enough sub- 
cutaneous tissues can be obtained locally; for 
the third and fourth fingers he used fascia lata. 
The flap is cut in a strip 3 inches by 1 inch, 
folded in half and sewed up into a bag which 
is slipped over the metacarpal head and 
secured by catgut. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



Si 




Fig. 112 (at left). Case i. E. M. End-result 2 months after arthroplasty. Volun- 
tary hyperextension 35 to 40 degrees. 

Fig. 113. Case 1. E. M. End-result plantar flexion, 2 months after arthroplasty. 



Hesse (84), in 1922, reported on fourteen 
cases of finger mobilization. On the middle 
joint, he made a lateral incision, resected the 
head of the basal phalanx after separation of 
the lateral ligaments. In two cases, a layer of 
periosteum from the tibia was placed over the 
resected end. In 10 months, one patient had 
complete working ability of the finger. In 3^2 
months, the other patient had active mobility 
of 120 degrees and normal extension. In the 
twelve other cases, free fascia lata transplan- 
tation was used. In ten cases, the patients were 
benefited, securing satisfactory mobility. In 
one case, the fascia sloughed and there was no 
betterment. In another case, there was short- 
ening to about 2 centimeters, active motion in 
the basal joint 100 degrees, but no movement 
in the middle joint and strong lateral motion. 
In four of the cases, it was necessary to remove 
the fascia. 

ANKLE 

Ankylosis of the tibio-astragaloid joint, if at 
a right angle without varus or valgus, is a 
functional joint with which, in my opinion, we 
should not interfere. Although a weight- 
bearing joint may be obtained from arthro- 
plasty, instability, pain, and sensitiveness may 
result. 

In a slight ankylosis of the ankle in good 
position, there is only a slight limp. If, after 
experience in years to come, stability may be 
assured with an arc of motion without pain 
and sensitiveness, then and only then will 
arthroplasty be indicated. 

Ochsner (i25),ini9i2, reported that in case 
operation was necessary for ankle deformities 
he used the resection method, removing the 
necessary amount of bone in a transverse line. 



His cases have been successful, and the 
patients can usually walk in 2 weeks. In case 
of severe ankylosis without deformity, hefis 
opposed to arthroplasty. 

Ashhurst (7), in 1915, cited the case of a boy 
with bony ankylosis of the right ankle, with 
the foot in a position of equinus at 140 degrees 
with the leg. There were deep scars on the 
leg and foot. Ashhurst incised down to the 
bone on the outer side of the tarsus from below 
the external malleolus to the extensor tendons. 
The soft parts were raised from the bones. 
Another incision 1 inch long was made on the 
inner side of the ankle joint in front of the 
internal malleolus and parallel to the tibia. 
The wounds were joined by burrowing. A 
wedge of bone, cut with its base on the dorsum 
of the tarsus and its apex at the posterior 
surface of the ankle joint, rendered the foot 
movable. Fascia lata from the left thigh was 
inserted. The result was free voluntary motion 
of about 10 degrees, with the foot not quite at 
a right angle. The hallux valgus caused ex- 
treme deformity. 

A second operation was performed in which 
the head of the metatarsal was removed and 
the toe put in position. The tendon of ab- 
duction hallucis was inserted. The tendo 
achillis was lengthened by the "Z" operation. 
One month later there was free voluntary 
motion in the ankle from 85 degrees to 95 
degrees and passive motion from 85 degrees to 
no degrees. Dr. Ashhurst looked for further 
improvement. 

One would hardly feel that 10 degrees 
motion in an ankle warranted the attempt to 
mobilize it. An ankylosis, corrected into 
proper position, would be useful and mobili- 



52 



SURGERY, GYNECOLOGY AND OBSTETRICS 




si~i? 



Fig. 114. Line of incision as used by 
author. 



'», OMldifia 





Fig. 115. Flap dissected back. 



Fig. 1 16. Fxcision of small amount 
of bone. 






Fig. 117. Rounding of distal end Fig. 118. Filing and smoothing of 

of metatarsus. metatarsal shaft. 



Fig. 119. Flap sewn in place. 



zation might result in a sore and painful 
joint. 

Steindler (174), in 1916, reported two cases 
in which pedunculated fascia flaps were used. 
One case was the result of a fracture of the 
astragalus and collum astragali, with supina- 
tion deformity, and the other the result of 
fracture of the internal and external malleolus 
and impingement of the body of the astragalus 
on the fractured end of the tibia and fibula. 
No results were recorded. 

Ceballos (30), in 191 7, used a free flap of 
fascia lata in a case of complete tibiotarsal 
ankylosis in a right angle. No result is 
given. 

Baer's (9, a) one case of arthroplasty on the 
ankle was reported in 1918. It is of interest, as 
a bone graft of fibula was inserted before the 
arthroplasty could be made. The membrane 
was inserted between the astragalus and the 
fibula. Voluntary motion of 30 degrees was 
obtained, and the patient walks with comfort. 



Reich (150), in 1919, issued his views on 
arthroplasty of the ankle joint, which he con- 
sidered one of the most satisfactory mobiliza- 
tions. Observations were made in various 
cases operated upon, which showed that the 
desired 20 degrees to 30 degrees range of 
mobility was not obtained. This, Reich be- 
lieved, was because in operation the tibia was 
again made concave and the astragalus con- 
vex. As the mobility attained by the natural 
joint is closely connected with the height of 
the astragalus over the posterior segment of 
the foot, the slightest diminution of this height 
interferes with the movement, for the margins 
of the concave plane of the tibia strike against 
the astragalus anteriorly and posteriorly. In 
arthroplasty a decrease in the height of the 
astragalus seems unavoidable. 

Reich recommended an inversion of the 
natural form of the portions of the joint, mak- 
ing the surface of the tibia convex and the 
astragalus concave. The flaps of fat are laid 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



53 





Fig. 120. Case i. D. R. Anteroposterior roentgenogram 
20 months after arthroplasty. 

between the surfaces. With this inversion, 
the axis of the joint mobility will be changed 
downward without the lateral ligaments being 
adapted to it, but this new mobility is not so 
much of the joint as of the rocking motion 
which furnishes a useful substitute for the 
former. 

METATARSOPHALANGEAL JOINTS 

The metatarsophalangeal joints, with the 
exception of the first metatarsophalangeal 
joint, never call for arthroplasty measures. 
These joints, in fact, are rarely stiff. The 
fascia-flap method gives an excellent result in 
the operation on the first metatarsophalangeal 
joint. 

Operative technique — author's method. After 
thorough preparation of the part and the 
application of a tourniquet, an incision is 
made, beginning on the lateral aspect of the 
first phalanx and extending parallel to the 
shaft, curving to the lateral dorsal surface 
over the region of the joint and then back to 
the lateral aspect of the first metatarsal (Fig. 
114). This flap is then dissected down and re- 
tracted with double hooks. A curved incision 
is then made through all remaining tissue, in- 
cluding bursa, capsule, and fascia. This in- 
cision begins near the base of the first meta- 
tarsal on the lateral plantar surface and 
sweeps about one-fourth inch over the base of 
the first phalanx to a corresponding position 
on the lateral dorsal aspect of the first 
metatarsal. The flap is dissected back, ex- 
posing the old joint (Fig. 115). About five- 



Fig. 121. Case 1. D. R. 
months after arthroplasty. 



Lateral roentgenogram 20 



eighths inch of the head of the first metatarsal 
is then removed and all edges smoothed with 
a file or shoemaker's rasp (very important) 
(Figs. 116, 117, 118). A chromic suture is then 
passed from the plantar surface into the 
cavity and through the flap, making a mat- 
tress suture, and then the needle is passed 
through the cavity to the outer plantar sur- 
face and the flap firmly pulled into the cavity 
over the end of the metatarsal head (Fig. 
119). The skin is closed with continuous 
catgut and a dry dressing applied. The toe is 
bandaged in inversion and slight plantar 
flexion, opposite to the usual deformity. 

Weight-bearing is allowed in 2 or 3 weeks, 
at which time passive motion and hydro- 
therapy are of use. Activity depends upon the 
amount of swelling and pain, and motion is 
limited accordingly. The results of mobiliza- 
tion of the joint are excellent. 

Case i. D. R., age 45. In February, 192 1, I 
operated for a case of double hallux valgus, using the 
technique I have outlined. 

For years this patient had complained of increas- 
ing pain and stiffening in the toe joints. More 
recently she complained of loss of motion and en- 
largement of the joints. Physical examination 
showed a marked exostosis on the top and inside of 
both toe joints, with limited motion. Excision of the 
distal head of the first metatarsus and insertion of a 
bursal flap was advised. 

February, 1921. In the operation 0.5 inch of the 
distal head of the first metatarsus was removed. 

April 8, 1 92 1. Good motion. Anterior arch 
padding. Subsequent convalescence without pain 
or swelling. Elastic cuffs advised. 

November 17, 1922. Motion perfect. (Figs, 
to 125.) 



120 



54 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 122. Fig. 123. 

Fig. 122. Case 1. D. R. Toes of right foot in dorsi- 
flexion 21 months after arthroplasty. 

Fig. 123. Case 1. D. R. Toes of right foot in plantar 
flexion 21 months after arthroplasty. 



Fig. 124. 



Fig. 125. 



Fig. 124. Case 1. D. R. Toes of left foot in plantar 
flexion 21 months after arthroplasty. 

Fig. 125. Case 1. D. R. Toes of left foot in dorsi-flexion 
21 months after arthroplasty. 



Murphy (120, b), in 19 13, secured good mo- 
tion in 18 days in a case of ankylosis of the 
phalangeal and metatarsophalangeal joints. 
Leucorrhcea of 4 years' duration had been the 
cause of stiffness. Murphy made an incision 
on the dorsum of the toe and used a flap of fat 
and fascia from the inner side of the foot with 
base upward. 

In 19 16, Murphy (i20,b) outlined his opera- 
tive technique for hallux rigidus as follows: 
A curved incision with convexity outward 
along the extensor tendon; incision of the 
tendon to elongate it; metatarsal head re- 
sected and bursal capsule used as the inter- 
posing flap. 

Putti (145, a), in 1913, reported an arthro- 
plasty on an ankylosed metatarsal phalanx of 
the hallux. He made a longitudinal cut on the 
internal side of the metatarsal phalanx, re- 
moved two large sesamoids that contributed 
to the stiffness, removed all capsule, and inter- 
posed a flap of fascia lata, wrapping the two 
surfaces. The extensor tendon was shortened. 
A plaster cast was applied to keep the hallux 
in a dorsal position. The postoperative treat- 
ment was regular. The stitches were removed 
on the ninth day, and gentle passive move- 
ment was begun. 

BIBLIOGRAPHY 



5- 
6. 

7- 

8. 



Ahrens. Muenchen. med. Wchnschr., 1908, iv, 2138. 

Albarran. Cited by Hoffa, loc. cit. 

Albee. Orthopedic and Reconstruction Surgery. 

1918, p. 965. 
Allison and Brooks. Surg., Gynec. & Obst., 1913, 

xvii, 645. 
Ameyaga, G. de. Ann. Surg., 1907, xlvi, 617. 
Appel. Deutsche Ztschr. f. Chir., 1916, cxxxvi, 508. 
Ashhxtrst. Ann. Surg., 1915, lxii, 302; 378. 
Axhatjsen, G. Beihefte z. med. Klin., Berl., 1908, 

iv, 23. 



10. 
11. 

12. 

13- 
14. 

15- 

16. 



17- 
18. 
19. 



20. 

21. 

22. 
2 3- 

24. 

25- 
26. 

27. 
28. 
29. 

3°- 

3i- 

32. 

33- 
34- 
35- 

36. 

37- 
38. 

39- 

40. 
41. 



Baer. (a) Am. J. Surg., 1918, xvi, 170. (b) Tr. 

South. Surg. Ass., 1916, 1917, xxx, 126. (c) Johns 

Hopkins Hosp. Bull., 1909, xx, 271. 
Baldwin. West London M. J., 1915, xx, in. 
Barton, J. Rhea. N. Am. M. & S. J., Phila., 1827. 
Bazy. Bull, et mem. Soc. chir., Par., 1907, xxxii, 520. 
Berard. Diet, de med., 1838, xxiii, 440. 
Beresowski. Cf. Orlow, Deutsche Ztschr. f. Chir., 

1903, xxxvi, 400. 
Berger. Bull, et mem. Soc. chir., Par., 1901, xxix, 

998. 
Biermann, Karl. Die funktionellen Resultate der 

Gelenkresectionen mit besonderer Beruecksichti- 

gung der Methoden zur Erhaltung der Beweglich- 

keit. Dissertation, Berlin, 1909. 
Bilczynski. Zentralbl. f. Chir., 1898. 
Blair. Tr. South. Gynec. Ass., 1914, xxvi, 435. 
Bockenheimer. Deutsche med. Wchnschr., 1922, 

xlviii, 729. 
Bolognesi. Arch, internat. de chir., Gand, 191 2-13, 

vi, 69. 
Brandstrup. Hosp.-Tied., K0benh., 191 7, No. 27, 

663. 
Brown. California State J. M., 1916, xiv, 146. 
Brown, W. L., and C. P. J. Am. M. Ass., Chicago, 

1914, lxii, 1389. 
Buchmann. Zentralbl. f. Chir., 1908, No. 19. 
Burlew. California State J. M., 1918, xvi, 237. 
Campbell, (a) J. Orthop. Surg., 1921, iii, 430. 

(b) Ann. Surg., 1922, Nov., 615. 
Carnochan. Arch, de med., i860, p. 284. 
Carr. Tr. South. Surg. Ass., 191 7, p. 161. 
Cavazzani. Gazz. d. osp., Milano, 1899, p. 37. 
Ceballos. Prensa med. argentina, Buenos Aires, 

1917, iv, 400. 
Ceccarelli. Riforma med., Napoli, 191 7, xxxiii, 

H73- 

Chaput. (a) Bull, et mem. Soc. chir. Par., 191 2, 

n.s., xxxviii, 452. (b) 1915, xli, 1540. 
Chlumsky. Zentralbl. f. Chir., 1900, xxvii, 921. 
Chubb. Brit. M. J., 1920, i, 256. 
Cieuentes. Rev. de espec. med., Madrid, 1909, xii, 

73- 
Clark. Med. Press. & Circ, Lond., 1914, n.s. xcvn, 

3°- 
Conrad. Dissertation, Kiel, 191 2. 

Corner. Med. Press. & Circ, London, 1913, n.s. 

cxvi, 723. 
Cotton. Surg. Clin., North America, 1922, ii. 
Cramer. Arch. f. kiln. Chir., 1901. 
Crosti. Atti d. Soc. lomb. di sc. med. e biol., 

Milano, 1916-17, vi, 48. 



MacAUSLAND: MOBILIZATION OF ANKYLOSED JOINTS 



55 



42. Czerny. Arch. f. klin. Chir., 1872, xiii, 227. 

43. Darling. Physician & Surg., 1913, xxxv, 71. 

44. Dartignes. Rev. d'orthop., 1900, xi. 

45. Dautrelpont. Arch. f. klin. Chir., 1868, ix, 917. 

46. Davis. Johns Hopkins Hosp. Bull., 191 1, Oct. 

47. Defontaine. Rev. de chir., 1887, No. 9. 

48. Delageniere. Bull, et mem. Soc. de chir. de Par., 

1917, xliii, 2195. 

49. Delbert. Gaz. med. d. Par., 1912, lxxxiii, 117. 

50. Delbet. (a) Bull, et mem. Soc. de chir. de Par., 1903, 

xxix, 1 1 72. (b) Ann. de la Policlin. de Par., 191 2, 
xxiii, 284. 

51. Denk. Arch. f. klin. Chir., 191 2, xcvii, 458. 

52. Deutschlander. Soc. des chir. de l'allemagne du 

sud-ouest, 1911, Nov. 

53. Diel. Gaz. d. hop., Par., 1913, lxxxvi, 1727. 

54. Douglas. Ann. Surg., 1920, lxxii, 636. 

55. Dufourmentel, L., and Darcissa. Bull. Soc. de 

pediat. de Par., 1921, xix, 62. 

56. Dupuy. These de doct., Toulouse, 1903. 

57. Duran, L. Rev. Ibero-Am. de cien. med., Madrid, 

1910, xxii, 366. 

58. Durante. Trattado di Medicina Operatoria di 

Durante e Leotta, vol. ii, Chirugia degli Arti, 113. 

59. Edmunds. Med. Press & Circ, 1912, xciv, 574. 

60. Eloesser. California State J. M., 1913, xi, 485. 

61. Ely. Bone and Joint Studies. Leland Stanford 

Junior Univ. Publications, 1916. 

62. Exner. Wien. klin. Wchnschr., 1913, xxvi, 1821. 

63. Ferguson. Med. Times & Gaz., 1861, i, 601. 

64. Finochietto. Semana med., Buenos Aires, 1918, 

xxv, 590. 

65. Foederl. Prag. Ztschr. f . Heilk., xvi, No. 4. Zentralbl. 

f. Chir., 1896, No. 5. 

66. Frisch, von. Wien. klin. Wchnschr., 1911, xxiv, p. 

922. 

67. Gallagher, P. J. Am. M. Ass., 1915, lxv, 1180. 

68. Gilbert. Texas State M. J., 1915, xxxi, 226. 

69. Gilpatrick. Boston M. & S. J., 1922, clxxxvi 374. 

70. Gluck, Th. Deutsche med. Presse, vii, 1. 

71. Goddu. Boston M. & S. J., 1921, clxxxiv, 198. 

72. Goebell, W. Muenchen. med. Wchnschr., 1913, lx, 

35°- 

73. Graff. Deutsche med. Wchnschr., 1915, xli, 1502. 

74. Grange, C. D'O. Lancet, Lond., 1920, ii, 554. 

75. Greiffenhagen. St. Petersb. med. Ztschr., 1913, 

xxxviii, 93. 

76. Hallopeau, P. Bull, et mem. Soc. de chir. de Par., 

1920, xlvi, 1447. 

77. Hamilton, G. Texas State J. M., Fort Worth, 1919, 

xiv, 353. 

78. Hammesfahr. Deutsche med. Wchnschr., 191 2, 

xxxviii, 390. 

79. Harris. Texas State J. M., Fort Worth, 1913, ix, 

213. 

80. Helferich. (a) Verhandl. d. deutsch. Gesellsch. f. 

Chir., 1894, xxiii, 504. (b) Zentralbl. f. Chir., 1894, 
suppl., p. 35. 

81. Henderson. Am. J. Surg., 1918, xvi, 30. 

82. Henle. Dissertation A. Lesser, Tuebingen, 1898. 

83. Herzberg. Dissertation, Berlin, 1913. 

84. Hesse, E. Arch. f. klin. Chir., 1922, cix, Jan. 1. 

85. Hessert. Surg. Clin., Chicago, 1918, ii, 129. 

86. Hoffa. Ztschr. f. orthop. Chir., 1906, xvii, 1. 

87. Hofmann. (a) Ztschr. f. orthop. Chir., 1906, xvii, 1. 

(b) Beitr. z. klin. Chir., Tuebingen, 1918, lix, 717. 

88. Hohlbaum. Arch. f. klin. Chir., 1922, cxvii, 647. 

89. Hohmann. Berl. klin. Wchnschr., 1918, lv, 222. 

90. Hohmeier and Magnus. Verhandl. d. deutsch. 

Gesellsch. f. Chir., 1914. 



91. 
92. 

93- 

94. 

95- 
96. 

97- 
98. 

99. 
100. 

101. 

102. 

103. 
104. 

io5- 
106. 

107. 

108. 
109. 
no. 
in. 



112. 
"3- 

114. 

"5- 
116. 

117. 

118. 

119. 
120. 



121. 
122. 
123. 

124. 

125. 
126. 
127. 
128. 

129. 

130. 

131- 
132. 

133- 



Hoke and Andrews. Atlanta J.-Rec. Med., 1908, x, 

132. 
Hoerhammer. Muenchen. med. Wchnschr., 191 7, 

lxiv, 1338. 
Huebscher, C. Corres.-bl. f. schweiz. Aerzte, xxxi, 

785- 
Huguier. (a) These de doct., Par., 1905. (b) 

Tribune med. Par., n.s., 1909, xli, 197. 
Imbert, L. Lyon chir., 1921, xviii, 572. 
Judet. Recherches de chir. experimentale. Paris: 

Baillere, 1908. 
Katzenstein. Berl. khn. Wchnschr., 1916, No. 24. 
Kennedy. Tr. Roy. Acad. M. Ireland, Dublin, 1915, 

xxxiii, 223. 
Kerr. Surg., Gynec. & Obst, 1920, xxx, 518. 
Kirschner. Verhandl. d. deutsch. Gesellsch. f. 

orthop. Chir., X Kong., Berl., 1910, 222. 
Klapp, R. Zentralbl. f. Chir., Leipz., 1909, xxvi, 

1196. 
Kleinschmidt. Muenchen. med. Wchnschr., 19 19, 

lxvi, 520. 
Kocher. Chirurg. Operations Lehre. 
Koenig. Lehrb. d. Chir., 1894. 
Kolazek. Beitz. klin. Chir., 1912, lxxviii, 155. 
Kuettner. Beitr. z. klin. Chir., Tuebingen, 191 1, 

lxxv, 1. 
Kusnetsoff. Vrach. St. Petersburg, 1898, xix, 

1275; 1311. 
Lentz. Cong, franc, de chir., 1895. 
Leriche, M. R. Lyon chir., 1921, xviii, 547. 
Lexer. Surg., Gynec. & Obst., 1908, vi, 601. 
MacAusland. (a) J. Am. M. Ass., 1915, lxiv, 312. 

(b) Surg. Clin., N. A., 1922, ii, 959. (c) Surg., 

Gynec. & Obst., 1921, xxxiii, 223. 
Mauclatre. Bull. med. Par., 1913, xxvii, 66. 
McCurdy. Pennsylvania. M. J., Athens, 1914-15, 

xviii, 606. 
McIlhenney. New Orleans M. J., 1901. 
McKenna. J. Am. M. Ass., 1917, lxix, 891. 
Meyer. Klin. Abend 18, October, 1895. 
Meyer, O. Deutsche med. Wchnschr., 1909, xxxv, 

i93i- 
Mikulicz. Verhandl. d. deutsch. Gesellsch. f. Chir., 

Berl., 1895, xxiv, 350. 
Moszkowicz. Berl. Ztschr. f. Chir., 191 7, cv, 168. 
Murphy, (a) Tr. Am. Surg. Ass., 1904, xxii, 313. 

(b) Ann. Surg., 1913, lvii, 593. (c) Murphy's 

Clin., 1914, iii, 523, 1159. (d) J. Am. M. Ass., 

1915, 851. (e) Murphy's Clin., 1916, v, 641, 189. 

(f) Tr. Am. Surg. Ass., 1913, xxxi, 67. (g) J. Am. 

M. Ass., 1905, xliv, 1479, 1573, 1671. 
Narath. Zentralbl. f. Chir., 1896. 
Neff. Surg., Gynec. & Obst., 1912, xv, 552; 592. 
Nelaton. Bull. et. mem. Soc. de chir. de Par., 

1902, xxviii, 687. 
Nelaton and Ombredanne. Rev. d. Orthop., 1905, 

25, vi, 39. 
Ochsner. Illinois M. J., 191 2, xxxi, 596. 
Oehlecker. J. Am. M. Ass., 1922, lxxix, 778. 
Ogilvy. New York M. J., 1921, cxiv, 566. 
Olivieri. Semana med., Buenos Aires, 1917, xxiv, 

127. 
Ollier. Traite des resections et des operations con- 

servatrices, etc., Paris, 1885. 
Orlow, L. W. Deutsche Ztschr. f. Chir., Leipzig., 

lxvi, 399. 
Osgood. Boston M. & S. J., 1911, clxv, 86. 
Owen. Ann. Surg., 1914, lix, 426. 
Painter. Canada Lancet, Toronto, 191 2-13, xlvi, 

332. 



56 



SURGERY, GYNECOLOGY AND OBSTETRICS 



134. Payr. (a) Deutsche Ztschr. f. Chir., 1914, cxxix, 341. 

(b) Arch. f. klin. Chir., Berl., 1914, cvi, 235. 

135. Pereira. Brazil-med., Rio de Jan., 1906, xx, 361. 

136. Perthes. Muenchen. med. Wchnschr., 1917, lxiv, 

9i9- 

137. Petraschewskaja. Verhandl. d. wiss. Ver. d. 

Aerzte d. stadt Obuchow-Krankenh. in St. Peters- 
burg, 22, 1913. 

138. Pettis. Physician & Surg., 1913, xxxv, 352. 

139. Phemister and Miller. Surg., Gynec. & Obst, 

1918, xxvi, 400. 

140. Plummer. Surg., Gynec. & Obst., 191 7, xxiv, 509. 

141. Pomponi. Gior. di med. mil., Roma, 1912, lx, 418. 

142. Prando. Prensa med. argentina, Buenos Aires, 191 7- 

18, iv, 399. 

143. Pringle. Tr. Roy. Acad. M., Ireland, Dublin, 1915, 

xxxiii, 220. 

144. Pupovac. Wien. med. Wchnschr., 1914, xxvii, 151. 

145. Putti. (a) Arch. d. orthop., Milano, 1913, xxx, 1; 

205. (b) Chir. d. organi di movimento, Bologna, 

1919, iii, 627. (c) J. Orth. Surg., 1912, iii, 421. 

(d) Chir. d. orig. di movimento, Bologna, 191 7, i, 1. 

(e) Arch. d. orthop., Milano, 1919, xxxv, 272. 

(f) J. Orth. Surg., Lincoln, Nebraska, 1920, ii, 530. 

146. Quentj. (a) Bull, et mem. Soc. chir., Par., 1902, 

xxviii, 724. (b) Ibid., 1903, xxix, 112. (c) Ibid., 
1905, xxxi, 622. 

147. Quigley, D. T., and Stevenson, E. C. West M. 

Rev., Omaha, 1913, xviii, 137. 

148. Rechet. VIII Cong, chir., Lyon, 1894; Arch. prov. 

Chir., 1896. 

149. Reiner. Deutsch. Ztschr. f. Chir., 1910, xiv, 209. 

150. Reich, A. Zentralbl. f. Chir., 1919, xlvi, No. 6, 97. 

151. Ringel. Deutsche med. Wchnschr., 1916, xlii, 713. 

152. Ritchie. J.-Lancet, 1920, xl, 479. 

153. Rocher. J. de med. de Bordeaux, 1920, i, 215. 

154. Rochet. These de Fondet, 1895. 

155. Rodgers. New York J. M. & S., 1840. 

156. Roepke. Deutsche chir. Kong., 1913, 116. 

157. Roeren. Arch. f. Orthop., Muenchen. u. Berl., 1922, 

xx, 36. 

158. Roser. Zentralbl. f. Chir., 1886, p. 36. 

159. Rovsing. Tr. XI North Surg. Cong., Gothenburg, 

1916. 

160. Ryerson. Surg. Clin., Chicago, 191 7, i, 197. 

161. Sayre. A New Operation for Hip joint in Bony 

Ankylosis. New York, 1869. 

162. Schanz. Muenchen. med. Wchnschr., 1904, p. 2228. 

163. Schloffer. Deutsche med. Wchnschr., 191 7, xliii, 

1183. 

164. Schmerz. Beitr. z. klin. Chir., Tuebingen, 1911, 

lxxvi, 261. 

165. Schmidt. Khirurgia, Moscow, 1899. 



166. Scudder. Boston M. & S. J., 1906, civ, 375; Ann. 

Surg., 1907, xlv, 297; 1908, xlvii, 711. 
168. Segale. Beitr. z. klin. Chir., Tuebingen, 1913, lxxxi, 

259- 

168. Sexsmith. J. Med. Soc. N. J., 1920, xviii, 333. 

169. Sievers. Freie Vereinigung der Chirurgen Sachsens, 

Leipzig, x, 191 2; Zentralbl. f. Chir., 1913, No. 23. 

170. Silfverskiold, N. J. Am. M. Ass., 1922, lxxviii, 856. 

171. Simon. Berl. klin. Wchnschr., 1914, li, 235. 

172. Sourdat. Med. prat., Par., 1910, vi, 806. 

173. Stein. Dissertation, Bonn, 1907. 

174. Steindler, A. J. Iowa State M. J., 1916, vi, 284. 

175. Sumita. Arch. f. klin. Chir., Berl., 191 2, xcix, 755. 

176. Tavernier. Lyon chir. 1920, xvi, 527. 

177. Taylor. Pennsylvania M. J., 1912, xvi, 294. 

178. Textor. Wurzburg, 1843, viii, 4. 

179. Thom, V. Deutsche Ztschr. f. Chir., Leipz., 1910-n, 

cviii, 424. 

180. Thomson. Edinburgh M. J., 1917, xix, 176. 

181. Torrey. J. Michigan M. Soc, 1913, xii, 318. 

182. Tubby, (a) Am. J. Orthop. Surg., 1914-15, xii, 433; 

377. (b) Med. Press & Circ, Lond., 1914, n.s. 
xcviii, 324. 

183. Tuffier. Soc. de chir. de R., 1901. 

184. Turner. Edinburgh M. J., 1914, n.s. xii, 433. 

185. Vaughan. G. T. Surg., Gynec. & Obst., 191 1, xiii, 

80. 

186. Verneuil. Arch, de med., i860. 

187. Verrall, P. J. Clin. J., Lond., 1920, xlix, 76. 

188. Vulpius. Muenchen. med. Wchnschr., 1914, Mar. 

i7- 

189. Weglowski. Zentralbl. f. Chir., 1907, Apr. 27. 

190. Werde. Deutsche med. Wchnschr., 1916, xlii, 1287. 

191. Wheeler, W. I. de C. Brit. J. Surg., Bristol, 1921, 

ix, 242. 

192. Whitacre. Lancet-Clin., Cincin., 1908, xcix, 424. 

193. Whitman. Ann. Surg., 191 1, liv, 860; 1916, lxiii, 

5°3- 

194. Wtenee. Am. J. Surg., N. Y., 1911, xxv, 281. 

195. Wille. Norsk. Mag. f. Laegevidensk., Kristiania, 

1911, ix, 40. 

196. Wollenberg. Ztschr. f. aerztl. Fortbild., Jena, 

1915, xii, 267. 

197. Wolff. Verhandl. d. deutsch. Gesellsch. f. Chir., 

1882. 

198. Woolsey. Ann. Surg., 1920, lxxii, 636. 

199. Zeller. Jahresk. f. aerztl. Fortbild., Muenchen, 

1919, xii, Hft. 25. 

Note. — Figures 56 to 63 and 87 to 92 are reproduced 
from the Surgical Clinics of John B. Murphy; Figures 64 
to 67 from Ann. Surg.; Figures 42 to 53 from Chir. d. org. 
di Movimento. 



A 



Reprint from SURGERY, GYNECOLOGY AND OBSTETRICS, July, 1922, pages 35-41 

RECURRENT DISLOCATION OF THE PATELLA 

With Report op Sixteen Cases 

By W. RUSSELL MacAUSLAND, M.D., Boston 

Surgeon-in-Chief, Orthopedic Department, Carney Hospital 

AND 

ARTHUR F. SARGENT, M.D., Boston 

Assistant Surgeon, Orthopedic Department, Carney Hospital 

NUMBER of factors play important number of slipping patella? rather weaken this 
roles in recurrent dislocation of the as a strong etiological factor. It is necessary 
patella. Trauma is unquestionably that the outer ridge of femoral condyles be 
important and frequent in the initial displace- poorly developed. Probably all postural de- 
ment. It is less important in recurrences, fects act as factors only secondarily through 
There is an inward twisting at the knee to- this associated developmental defect, 
gether with a blow or pressure on the outer 4. Flat feet give static strain on the inner 
side of the leg, and associated with this is side of the knee joint and may contribute that 
always a strong sudden contraction of the additional twist which aids displacement, 
quadriceps muscle. 5. Elongated patella tendon with relaxed 

Recurrent outward displacement of the synovial membrane and capsule, both usually 

patella is a lesion peculiar to young girls due to chronic synovitis. The distention 

during their growing period and tends to of the joint causes stretching of all the 

persist into adult life. Usually the first retaining structures. 

displacement occurs between the ages of 6. Imperfect development in size and 
12 and 18 years and this initial displacement shape of the patella in relation to the ex- 
is more painful and disabling than subse- ternal condyle will allow the patella to slip 
quent ones. Injury and excessive knock- more easily to the outer side, 
knee are the chief etiological factors. The 7. Imperfect development in the size and 
displacement occurs with the strong con- shape of the external condyle is important, 
traction of the quadriceps muscle, usually Graser (9) did a supracondylar osteotomy 
early in the act of knee flexion, since in in one case in which he felt this faulty rela- 
ten to twenty degrees' flexion, the femur tion required correction, 
easily rotates inward on the tibia and an That the external condyle is occasionally 
exaggeration of the knock-knee takes place, underdeveloped and does not thereby offer 

There is a long line of contributing factors a bony resistance to the displacement, is ac- 

which aid these recurrences. Among these knowledged by Albee (2) who has used a bone 

are found so many common postural condi- graft to correct this anatomic defect, tilting 

tions affecting the knee joint that it seems the outer rim of patellar surface of the femur 

improbable that they alone can be the excit- to block the lateral thrust of the patella, 

ing etiological factor. The most constant Of the above lesions, the lateral tendon 

contributing factors are: attachment and the faulty condylar develop- 

1. Heredity. Abnormal mobility and laxity ment are the most constant pathological 
of the knee, associated with poor general pos- findings. Static defects and capsule relax - 
ture are occasionally hereditary peculiarities, ation are important in releasing the normal 

2. Weakness of the quadriceps extensor factors restraining displacement, 
muscle with resultant laxity of structures 

about the knee joint. diagnosis 

3. Static defects. Knock-knee has been The patient usually makes the diagnosis, 
long associated with this lesion but the giving the history of (a) severe initial dis- 
frequency of knock-knee and the infrequent placement, (b) recurrences, (c) constant fear 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Figs, i and 2. Jones knee brace with pad attached. 

lest displacement recur — with resultant in- 
activity. 

The initial attack is most painful. The 
knee is flexed and the patella is found on 
the outer side of the condyle. Following 
reduction, expecially in the initial attack, 
an acute synovitis develops. 

TEEATMENT 

A. Acute attack. The treatment of the 
initial attack calls for immediate reduction 
of the displacement. This can usually be 
accomplished by sudden extension of the 
leg with pressure of one hand against the 
outer condyle, pushing the patella to the 
median line. The injury calls for immobili- 
zation by means of plaster for 3 weeks, and 
were this done following the original injury 
recurrences would be less frequent. 

B. Recurrent attacks. The treatment of 
recurrent attacks may be divided into (1) 
supportive, (2) stimulative, (3) correction of 
static errors, (4) operative. 

1. Supportive treatment in the earlier at- 
tacks usually gives the patient confidence. 
This may be obtained by the use of a split 
knee cap with a crescentic pressure pad to aid 
in holding the patella in place or it may re- 
quire a Jones knee brace with a pad attached 
(Fig. 1). These should not be used with- 
out stimulative treatment, and if used too 
long are apt to cause varicose veins and 
oedema of lower leg from constricting straps. 

2. Stimulative treatment consists of (a) 
baking and massage, which will to a degree 
give tone to the relaxed ligaments; (b) ex- 
ercises to strengthen muscles and ligaments 
and to develop postural strength. 



3 . The correction of static errors is mos 
important. In many of these cases there i 
marked abduction of the feet (weak or fla 
feet). This should be corrected in all case 
by the Whitman type of foot brace. Thi 
correction counteracts in a mild degree ; 
moderate knock-knee. In spite of conserv 
ative measures, the knee frequently remain 
not dependable. In such cases operatioi 
should be considered. 

4. Operative methods. The operative meth 
ods are (a) capsulorrhaphy, (b) transplanta 
tion of part of patella tendon, (c) transplanta 
tion of bony insertion of patella tendon. 

Capsulorrhaphy . Alone this operation ha 
been a distinct failure. In conjunction wit] 
other procedures, it might be used, providec 
the length of time of the disability has beei 
such as to cause the inner capsule to rela: 
markedly and secondary deformities to de 
velop. The authors have never done this, how 
ever, either alone or in conjunction with th< 
following methods. 

Transplantation of part of patella tendon 
In the early cases of the authors, this pro 
cedure was followed, all cases showing gooc 
results. The objections, however, are — ■ 

1. Twisting of half of the patella tendon 
which, although bringing more tautness be 
tween outer side of patella and externa 
condyle, is open to the danger that relax 
ation of this tendon may take place. Ii 
general, a muscle cannot function in tw< 
places at once. 

2. Splitting of tendon, sewing and handling 
ends cause them to fray and make it im 
possible to secure a clean, firm anatomii 
attachment, whether subperiosteal or int< 
a bony cavity. The patella tendon is sur 
prisingly thin and, on account of this tend 
ency to fray, it is almost impossible t( 
suture. We have, therefore, come to us< 
only the bony transplant operations. 

Technique of transplantation of patella ten 
don (Figures 3, 4, 5, 6 and 7). Usual two 
day preparation. Tourniquet. 

A curved incision is made from the innei 
side of the patella well down over the attach 
ment of the patella tendon (Fig. 3) . The skir 
is clamped off with towels. The patella ten 
don is exposed to view. An incision is mad< 



MacAUSLAND AND SARGENT: RECURRENT DISLOCATION OF PATELLA 





Fig. 3. Drawing showing line of incision. 

through the thin fibrous covering of the ten- 
don which is then gently retracted and 
preserved as far as possible for resuture 
(Fig. 4). An incision through the center of 
the patella tendon is then made from the 
patella to the tubercle (Fig. 5), cutting it off at 
this point on the outer half. This half is 
then quilted with chromic catgut No. 3, 
turned in under the inner remaining half 
and sutured in a bony groove as far as possi- 
ble to the inner side, on the inner face of 
the tibia (Fig. 6). The periosteum is then 
pulled over this insertion and the thin cap- 
sule pulled over these tendons (Fig. 7). The 
skin is closed with continuous catgut No. 2. 
Dry dressing is applied, followed by plaster 
from the toe to the groin. This plaster re- 
mains on for 10 weeks and is followed by 
gentle passive movements, baking and mas- 
sage of thigh and calf, and increasing use. 
(See report of cases by authors, 1, 2, 3, 7, 8, 
and our cases 12, 14, and 15.) 

Transplantation of the bony insertion of the 
patella tendon. (Figs. 3, 8, 9.) This procedure 
appeals from an anatomic standpoint as well 
as being practical and simple. The tendon 
is neither weakened nor traumatized . There is 
no suture through tendon and tendon strength 
is preserved. Results are excellent. (Cases 
from literature, 4, 8, our cases 13 and 16.) 

Operative technique. Two-day preparation. 
Tourniquet. 



Fig. 4. Cutting outer half of patella tendon in slipping 
patella. 

A long curved incision is made halfway 
between the inner condyle and patella, curv- 
ing over the tibial tubercle. The skin wounds 
are clamped off with towels, and the patella 
tendon with fascial covering is exposed. A 
light incision is made through the fascia 
from the inner border of patella to below the 
tibial tubercle; this covering is dissected, 
quickly clamped and retracted to right and 
left to be resutured later over the tendon. 
A wedge of bone the size of a thumb-nail 
is then removed, including the attachment 
of the inner half of the patella tendon. The 
patella tendon is split in half and a similarly 
symmetrical bony wedge removed from the 
inner surface of the tibia at a point that will 
take the tendon bone graft. The bony 
transplant is forcibly wedged into its new 
bed, the periosteum sutured with fine chro- 
mic gut, the light fascial covering resutured, 
and the skin closed with continuous catgut 
No. 2. Plaster is applied from ankle to groin 
and should remain on for 10 weeks. Follow- 
ing this, gentle motions, use, and massage 
should be conscientiously carried out. 

CASE ABSTRACTS 

Case 1. K. A., age 18, first seen March, 1915. The 
left knee cap had slipped out of place 3 or 4 years 
ago following injury to knee. Four months later 
while playing tennis "knee went out" again. Since 
then this has recurred at intervals. Physical exam- 
ination was negative except for local condition. Any 
attempt to move left patella is received in a very 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 5. Operation for transplantation of patella tendon. 
Note skin incision and the incision through the fascia 
covering tendon. Note longitudinal division of tendon. 

Fig. 6. Running a line of silk sutures up and down the 
upper half of the patella tendon. 

apprehensive manner by the patient, especially 
when it approaches the external condyle. Slight 
pronation of both feet. X-rays of knee are negative. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of the outer half of 
the patella tendon into the periosteum of the tibia. 

Result. Up to March, 1920 (5 years), there had 
been no recurrence. Perfect function. 

Case 2. Miss R., age 17, first seen August, 191 2. 
Fourteen years ago patient fell against an oil stove 
and pushed the patella out. Since then this has 
slipped out at various intervals. Physical examina- 
tion showed very relaxed capsule on the inner side. 
Any attempt to displace patella is very painful. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of the outer half of 
patella tendon into the periosteum of the tibia. 

Result. Perfect function of knee. No recurrence 
to date (9 years). 

Case 3. T. K., age 23, first seen in April, 1918. 
About 5 years ago following an injury to the right 
knee, the right patella began dropping to one side. 
Has been treated with plaster casts, etc. Since the 
first attack the patella has slipped out seven different 
times. Physical examination was negative, except 
for local examination. The right knee is slightly 
swollen. All motions are limited and very painful. 
No surface heat. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of the bony insertion 
of patella tendon into tibia. 

Result. Perfect function. No recurrence to date 
(3K years). 

Case 4. I. H., first seen February, 1917. Since 
childhood has had a weak right knee which often 
twisted without warning, causing patient to fall to 
the ground, after which knee would be swollen and 



Fig. 7. Note the external half of the patella tendon has 
been sutured, passed under the internal half and is sutured 
subperiosteally. The wound is closed in the usual manner 
with continuous catgut suture. 



very painful. Following a fall, 3 years ago, right 
knee has been limited in motion. Physical examina- 
tion was negative except for local condition. The 
right knee is swollen and tender. Patella approaches 
outer side of knee. Extension is normal, flexion is 
painful and limited. The patella slips to outer side 
of knee when knee is flexed. Some grating under 
patella on motion. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of bony insertion of 
patella tendon into inner side of tibia. 

Result. Good function, no recurrence. January, 
192 1 : "On the whole it seems to be greatly im- 
proved. There is no slipping of the knee-cap and, 
although it is somewhat weak and occasionally 
wrenches enough to throw me, it does not hurt as it 
used to and no swelling follows. I have a little more 
than half motion, but do not limp at all." 

Case 5. A. C., first seen June, 191 1. Fifteen 
years ago patient fell through a piazza, striking on 
left knee. Since then has had attacks of patella 
slipping toward the outside of the knee, causing 
extreme pain and discomfort often lasting several 
hours. Last attack 2 years ago and since then knee- 
cap has been very loose. Physical examination 
shows left patella freely movable and can be carried 
well beyond median line on outer side. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Capsulorrhaphy (by another surgeon). 

Result. (?) Case has been lost. 

Case 6. W. T., first seen July, 1906. Four years 
ago patient fell, striking on the outer side of the left 
foot, bending the knee inward. After that the knee 
has often "given out from under him." Feels in- 
secure and has been wearing knee-cap and bandage. 

The patella tendon is loose and attached to- 
ward the outer side of the median line of leg. It is 
also tilted down to the outer side of the knee. The 



MacAUSLAND AND SARGENT: RECURRENT DISLOCATION OF PATELLA 




Figs. 8 and g. Showing method of transplanting bony insertion of patella tendon. 



internal condyle is prominent. The leg cannot be 
fully extended and there is slight crepitation under 
the patella. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of the outer half of 
the patella tendon into periosteum of tibia. 

Result. Not satisfactory. Previous operation did 
not accomplish all that was desired so about 8 
months later a rotation osteotomy was done just 
above adductor tubercle, the condyles being placed 
in their normal relationship. This operation resulted 
in normal function of the knee. 

Case 7. B. D., first seen July, 1908. Knees have 
always turned in. Left knee has "given way under 
her" when walking. Has had several attacks during 
the last few years. Physical examination shows 
knees in semi-valgus position. There is also about 
5 degrees' lateral mobility in full extension. Both 
patellae are abnormally movable. The tibial tubercle 
is congenitally misplaced, being nearer the external 
edge of tibia than is normal. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of outer half of patella 
into periosteum of tibia. 

Result. Immediate result good but patient has 
since disappeared. 

Case 8. J. M., first seen November, 1904. About 
12 years ago patient's knees began to "give way" 
from beneath her. The attacks came suddenly and 
she would fall. These occurred at intervals of weeks, 
always associated with swelling of the knee and "it 
always felt as if something came out from the inside 
of her knees." Physical examination was negative, 



except for local condition. Motions of knees are 
normal. On complete flexion, the patellae move 
toward outer aspect of knee. Patient has a slight 
knock-knee. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of the outer half of 
patella tendon into periosteum of tibia. 

Result. Normal function. No recurrence to date 
(17 years). 

Case 9. Mrs. T. C. K., first seen March, 191 2. 
Patient has had trouble with her feet for years. At 
the age of 10 years her left knee began to slip out at 
frequent intervals. Six years later .her knee was 
operated upon by another surgeon, a reef being 
taken in the capsule. The knee remained well for 4 
years when it began to slip out again in spite of the 
leather braces and knee-caps she had been wearing. 

Diagnosis. Slipping patella. 

Treatment. Capsulorrhaphy (by another surgeon). 

Result. Failure. 

Case 10. A. B., first seen August, 1915. About 
19 years ago, left knee-cap slipped out for the 
first time. This has since recurred at frequent inter- 
vals. Four years ago, this knee was operated upon 
for this condition. Several hours (?) ago the patient 
tripped, fully flexing the knee. The patella was dis- 
placed laterally forcing the femoral condyles 
through the inner capsule, the tear being from the 
inner tuberosity and the front of the tibia. Patella 
tendon is intact. 

Diagnosis. Recurrent dislocation of left patella 
and ruptured internal lateral ligament. 

Treatment. Light plaster cast. Operation later. 

Result. Good function. 



SURGERY, GYNECOLOGY AND OBSTETRICS 
SUMMARY OF AUTHOR'S CASES 



No. 


Name 


Date 
First Seen 


Original 
Injury 


Static 
Defects 


Treatment 


Result 


Remarks 


i 


K. R. 


Mar., ioi5 


Slight trauma 


Weak feet. 


Tendon transplantation 


Good 


No recurrence 


2 


Miss R . 


Aug., igi2 


Dislocation of 
patella 


? 


Tendon transplantation 


Good 


No recurrence 


3 


T. K. 


Apr., igi8 


Contusion 


? 


Tendon bone trans- 
plantation 


Good 


No recurrence 


4 


I. H. 


Feb., 1917 


Twist 


? 


Tendon bone trans- 
plantation 


Good 


No recurrence 


5 


A. C. 


June, 191 1 


Contusion 


? 


Capsulorrhaphy 


? 




6 


W. T. 


July, igo6 


Contusion 


? 


Tendon transplantation 


Poor 


Eight months later 
osteotomy done and 
condyles placed in 
normal relationship 
Good result then. 


7 


B. D. 


July, igo8 


None 


Tibial tubercle mis- 
placed outward. 


Tendon transplantation 


Patient lost track 
of 


Immediate result good. 


8 


J. M. 


Nov., igo4 


None 


Slight knock-knee. 


Tendon transplantation 


Good 


No recurrence 


9 


Mrs. T.C.K. 


Mar., igi2 


None 




Conservative capsulor- 
rhaphy 


Poor 


This case previously 
operated upon by 
another surgeon and 
capsule reefed with- 
out improvement. 


IO 


A. B. 


Aug., 1915 


None 


None 


Conservative 


Good function 




II 


Mrs. T. S. M. 


Oct., igig 


None 


Flat feet 


Conservative 


No improvement 


Operation later 


12 


E. H. T. 


Oct., igo4 


Contusion 




Tendon transplantation 


Good function 


No recurrence 


13 


L.D. 


Nov., 1919 


Twist 


None 


Bone transplantation 


Excellent 


No recurrence 


14 


L. A. S. 


Oct., 1911 


Contusion 




Tendon transplantation 


Function normal 


No recurrence 


15 


M. H. 


Nov., 1908 


None 


None 


Tendon transplantation 


Function normal 


No recurrence 


16 


Miss M. R. 


Aug., 192c 


Contusion 


None 


Bone transplantation 


Function normal 


No recurrence 



Case ii. Mrs. T. S. M., first seen October, 1919. 
For the last 24 years both knee-caps have been 
slipping out. These attacks come on very suddenly 
and are very painful. The patient has been wearing 
supports for the knees. Physical examination 
shows both feet slightly flattened with a moderate 
hallux valgus. The patient is wearing very tight 
split knee-caps which are causing swelling of the 
lower legs. 

Diagnosis. Slipping patellae (double). 

Treatment. Conservative. Operation later. 

Result. No improvement. Refuses operation and 
still has recurrent displacements. 

Case 12. E. Ff. T., first seen October, 1904. 
About 4 years ago, patient fell on knee and was con- 
fined to bed for a month with leg in splints. Two 
and one-half years ago she fell again, and remained 
in bed 2 months. Three months ago, she again fell 
and had to push patella back in place. Cast worn 
one month. Physical examination negative except 
for local condition. The entire musculature of the 
right leg is flabby and the power in this limb is con- 
siderably diminished. Both patellae are more mov- 
able than normal. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of outer half of the 
patella tendon into periosteum of tibia. 

Result. Function normal. No recurrence to date. 

Case 13. L. D.. first seen November, iqiq. Five 
years ago patient twisted the left knee. Laid up a 
week. One year later fell again, this time striking 
on the right knee. A year later her knee slipped out 
five or six times, always accompanied by pain and 
swelling. Physical examination shows a moderate 
amount of fluid in the right knee and any attempt 
to push the patella to the outer side is very painful. 



Diagnosis. Slipping patellae, and operation is 
recommended. 

Operation. Transplantation of the bony insertion 
of the patella tendon in tibia. 

Result. No recurrence; excellent function; no 
subjective symptoms. 

Case 14. L. A. S., first seen October, 1911. Nine 
years ago the patient injured the knee which became 
swollen and painful. Patient was unable to walk. 
Knee-cap has slipped out twice in the last 2 years. 
Physical examination shows patella unusually mo- 
bile. Can almost be thrown off to outer side with 
ease. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of outer half of pa- 
tella tendon into periosteum of tibia. 

Result. No recurrence. Function normal to date. 

Case 15. M. Ff., first seen November, 1908. Left 
knee-cap has slipped out many times within the 
last 3 years. Physical examination was negative 
except for local condition. Left knee is moderately 
swollen. Fossae on either side obliterated. Slight 
increase in surface temperature. Complete extension 
of knees possible with difficulty. Both patellae ten- 
dons are elongated, those on the left more than the 
right. Tibial tubercle is external to mid-line of 
patella; the pull of the patella tendon is, therefore, 
obliquely outward, the patella being tilted. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of outer half of 
patella tendon into periosteum of tibia. 

Result. No recurrence. Function normal. 

Case 16. Miss M. Ff., age 28, first seen August, 
1920. In 191 5, patient struck right knee against a 
chair sustaining an injury which kept her in bed for 



MacAUSLAND AND SARGENT: RECURRENT DISLOCATION OF PATELLA 



6 weeks. After that she was unable to use the knee 
even with a knee-cap and "it kept slipping out." 
Following each attack she was "laid up" from 6 to 
8 weeks. Last attack July 7, 1920, following which 
she was confined to bed until September 6, 1920. 
Physical examination was negative, except for con- 
dition of right knee, which is swollen. All motions 
are painful, especially on moving the patella outward. 

Diagnosis. Slipping patella, and operation is 
recommended. 

Operation. Transplantation of bony insertion of 
patella tendon. 

Result. Excellent function. 

BIBLIOGRAPHY ABSTRACTS 

Goldthwait in February, 1904, reported 11 cases of 
slipping patellae with the following results: 1 case where 
tendon was transplanted with its bony insertion with 
good result; 5 cases where tendon was transplanted into 
periosteum with good result; 2 cases where tendon was 
transplanted into periosteum, not good result; 2 cases 
where capsule was quilted with not good result. 

Krogius in Zcntralbl. f. Chir., Mar. 5, 1904, reported 2 
cases (one double) where patella was drawn outward by 
tense outer portion of the capsule. He operates as follows: 
(1) approach the knee by Kocher incision; (2) incision 
from slightly above the patella, down a few inches in 
front of its outer edge to insertion of ligamentum patellae; 
through the iliotibial band, tendinous expansion of vastus 
externus and fibrous capsular wall; (3) formation of 
bridge-shaped flap on inner side of patella connecting 
below with the tendinous expansion of vastus internus and 
fibrous capsule and above with muscle and fascia; (4) 
transplantation of the flap, left attached at both sides, 
across patella at its outer edge. 

Result. First case: after 6 months patella slipped out 
again. Second case: result perfect after 3 months. 

Whitlock in British Journal of Surgery, July, 1914, 
gives technique as follows: (1) reefing medial side of cap- 
sule with or without opening joint; (2) transplanting in- 
sertion of patellar ligament medially; (3) reinforcing the 
patellar ligament by grafting tendon of gracilis into it. 

Dumferline in Surgery, Gynecology and Obstetrics, 
April, 1912, describes his technique as follows: patellar 
ligament is split, portion is turned up and sutured to the 
cut end of the tendon of the semitendinosus with chromic 
catgut. Capsule and fascia are then reefed. 

Murphy's technique is given in Murphy's Clinics vol. iii, 
No. 4, August, 1914, as follows; Joint exposed freely by 
two longitudinal incisions, one on either side of the patella, 
turning the patella with the ligamentum patellae to one 
side. Segment of bone between condyles removed to 
deepen the groove. Flap of fat and fascia then turned in 
from above and sutured over the denuded bone area to 
prevent ankylosis of patella to femur. Patella then 
replaced. 

GTaser'mDeutscheGesellsch.f. Chir., andZentralbl.f. Chir., 
July 9, 1904, reports a case where outer condyle of femur 
stood considerably farther backward than inner condyle 
when leg rotated outward. He operated by doing a 
supracondyloid osteotomy of femur and twisting the con- 
dyles so as to bring outer portion forward and inner con- 
dyle farther back. 

Albee in Orthopedic and Reconstruction Surgery describes 
his technique as follows: 

"A semilunar skin incision is made at the outer border 
of the patella sufficiently long to reach below the tibial 
tubercle and to a point above the external condyle. Avoid- 



ing undue disturbance of the underlying joint structures, 
the external condyle is penetrated with a broad thin osteo- 
tome on its external surface, making a bone incision from 
iK to 2 inches long, and situated about \}4 to yi inches 
below its anterior articulated surface and nearly in line 
with the long axis of the femur. This bone incision al- 
lows the anterior surface of the external condyle to be 
elevated to a plane above the internal condyle, by pro- 
ducing a greenstick fracture near the intercondylar groove, 
the object being to place a permanent and rigid obstacle 
in the way of outward displacement of the patella. 

"When the anterior segment of the external condyle has 
been obliquely elevated to a sufficient degree to secure the 
desired obstructing effect, the width of the bone-gap thus 
formed is measured, and a section of bone sufficiently large 
to fill this cuneiform opening is removed from the crest of 
the tibia through the lower portion of the original skin 
incision, extended below the tubercle for this purpose. 
This bone-graft wedge can be easily and quickly procured 
by the use of the motor-saw. Before the graft is removed, 
it is drilled obliquely in one or two places with a motor- 
drill so that it may be pegged to the under portion of the 
external condyle after it has been put in position. Dowel 
pins, made from an additional portion of the bone removed 
from the crest of the tibia at the time the graft is obtained, 
and rounded by the motor-lathe to fit the drill holes in the 
graft, are driven into place. 

"The cancellous structure of the condyle is easily 
penetrated by the bone-graft pins, but if any difficulty is 
encountered, the motor-drill can again be inserted into the 
holes already made in the graft and these prolonged into 
the external condyle. The ligaments and tendinous ex- 
pansions are sutured over the graft with kangaroo tendon, 
thus securely holding the elevated portion of the condyle. 
The skin wound is closed with a continuous mattress suture 
of plain catgut, without drainage, and the leg from toes to 
groin is encased in a plaster-of-Paris splint in which it is 
allowed to remain for 3 weeks; at the end of this time 
passive motion and massage are begun. 

"The advantages of this procedure are that with no 
sacrifice of joint cartilage, a minimal amount of joint 
injury is produced at the time of operation, thereby greatly 
lessening the dangers of limitation of motion and the forma- 
tion of adhesions, and that the permanent blocking of any 
further tendency to displacement of the patella is effected 
by the actual elevation of the external condyle or an actual 
restoration of the normal mechanico-anatomical conditions. 
The soft parts are not interfered with. The only further 
suggestion in the case of extremely lax and stretched inter- 
nal capsular ligaments is their plication with kangaroo 
tendon; this, however, is usually unnecessary, for if the 
external condyle is propped well forward, all requirements 
are fulfilled. " 

BIBLIOGRAPHY 

1. Tubby, A. G. Deformities Including Diseases of the 

Bones and Joints. Vol. i, chap, ii, p. 313. 

2. Albee, F. G. Orthopedic and Reconstruction Surgery. 

Philadelphia: Saunders Co., 1919, p. 624-630. 

3. Goldthwaite, Joel E. Slipping or recurrent disloca- 

tion of patella. Boston M. & S. J., 1904, cl, 169. 

4. Idem. Permanent dislocation of the patella. Ann. 

Surg., 1899, Jan. 

5. Krogius. Zentralbl. f. Chir., 1904, Mar. 5. 

6. Whttlock. Brit. J. S., 1914, July. 

7. Dumferline. Surg., Gynec. & Obst., 1912, April. 

8. Murphy. Murphy's Clinics, 1914, iii. 

9. Graser. Deutsche Gesellsch. f. Chir. and Zentralbl. 

f. Chir., 1904, July 9. 



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1922. 





TRANSPLANTATION OF THE ENTIRE FIBULA IN CASES OF 
LOSS OF TIBIA FROM OSTEOMYELITIS 

By W. Russell MacAusland, M.D. 

of Boston, Mass. 
surgeon-in-chief, orthopaedic dept., carney hospital 

AND 

Arthur F. Sargent, M.D. 

ASSISTANT SURGEON 

In April, 1912, the author * reported the results of the transplantation 
of the entire fibula as a substitute for the loss of the tibia in the same leg 
following osteomyelitis. The values of such transplants are several : First, 
the dangers from infection following a small exposure are largely minimized, 
as compared with a tibial graft. Second, failure is practically impossible, 
owing to the fact that the blood supply of the fibula is not disturbed. Third, 
the bone rapidly hypertrophies to take up the added weight and leaves no 
defect from the absence of the fibula. Fourth, fracture of graft is impossible. 

The entire transplantation is, of course, used only in those cases following 
osteomyelitis of the tibia where no regeneration has occurred and the dis- 
ability therefore is complete. 

In practically all cases of osteomyelitis of the tibia, the upper and lower 
epiphyses remain the limiting barriers and are undisturbed so that the growing 
portions are not usually totally destroyed. 

Technic of Transplantation. — Following careful preparation of the leg, 
an incision three inches long is made between the head of the fibula and the 
head of the tibia (see Drawing No. iA) (Fig. 11) being careful not to injure 
or divide the peroneal nerve as it passes over the fibula. 

The remaining tibia is then cupped out to take the fibula graft. 

A longitudinal slit is then made in the periosteal covering of the upper 
fibula and the outer half gently freed from the fibula. The fibula is then 
osteomized as high as thought practical and by means of heavy traction is 
pried into this tibial cup. It is usually best to deepen this cup a little, thereby 
gaining better and quicker union. (See Drawing No. iB.) (Fig. 12). 

By leaving the periosteum on the outer side of the fibula intact both to 
the remaining fibula head and to the outer transplanted shaft, we gain a 
periosteal bridge which will often develop a bony bridge, thus more efficiently 
uniting the fibula and tibia. (See Cases I, II and III.) 

The use of wire is unwise as union is always delayed in the presence of 
a foreign material. The wound is closed in the usual manner and a plaster 
applied from the toe to well above the knee. This remains on for two months, 
after which, a similar operation is performed on the lower leg. (See Drawing 
No. 2A and 2B) (Figs. 13 and 14) and diagrammatic sketch. (Fig. 10). 

91 



MacAUSLAND AND SARGENT 

Usually two months following the second operation, weight-bearing is 
permitted, and either plaster or a caliper brace is used for a period of six 
to eight months. 

It is surprising how quickly bone hypertrophy follows in the fibula with 
this added responsibility. 

Note that the hypertrophy in Case I reached nearly the proportion of a 
normal tibia. 

Observations. — i. Union is solid and takes place in record time. 

2. The fibula hypertrophies, as seen in Case I of seven years' standing, 
and in Cases II and III of four and a half years and nine years. 

3. Growth of leg continues and does not seem to be retarded. 

Case I. — A. L. This was a case of a young girl who in January, 1915, had an 
osteomyelitis of the left tibia and the right femur. She was admitted to the 
hospital on June 10, 1912. 

Physical Examination. — Negative except for the local examination, which 
showed many discharging sinuses over the left tibia and the right femur. Wasser- 
mann negative. 

On June 25, 1915, the entire tibia was removed from the epiphysis to epiphysis 

and plaster cast applied from groin to toes. Femur curetted, troughed and packed. 

On March 1, 1917, there was no regeneration of the tibia — all wounds healed. 

February, 1918, upper end of fibula transplanted into upper epiphysis of tibia — 

wound healed with only slight discharge in three weeks. 

November 4, 1920, lower end of fibula transplanted into lower tibial epiphysis. 
Wound healed in three weeks. Plaster case applied following each transplant 
from toes to groin. (See X-rays, Figs. 1, 2, 3, and 4.) 

Functional result excellent seven years after operation. 

Case II. — N. G. This is the case of a young boy who had an acute osteo- 
myelitis of the tibia in April, 1917, which resulted in marked destruction of the 
greater part of the tibia. This osteomyelitis was treated up to November, 1917, 
when the wound was healed. On May 23, 1918, the fibula was transplanted into the 
epiphyses of the tibia as in the previous case. 

March 17, 1919, X-rays show hypertrophy of the fibula. (See X-rays, Figs. 
5 and 6.) 

Functional result excellent four years following transplantation. 
Case III. — L. B. This young girl, at the age of thirteen, was seen by her 
physician for pain and discharge of the lower leg. Two years' duration. At the 
first onset the pain had been sudden, accompanied by temperature ranging from 
101 degrees to 104 degrees. Three operations were performed, each consisting 
of the removal of a portion of the tibia. 

April 15, 1909, this case was seen by one of the writers and the examination 
showed four discharging sinuses along the tibia. A diagnosis of chronic osteo- 
myelitis was made and X-ray showed the whole tibia honeycombed and prac- 
tically sequestrated. 

Operation.— May, 1909, the whole tibia excised, only the epiphysis remaining. 
The periosteum resutured. 

November, 1909, as there was no evidence of an attempt to regenerate a new 
tibia, the upper end of fibula was transplanted into the upper epiphysis of the 
tibia; the wound healed in two weeks. 

December 31, 1909, the lower end of the fibula was transplanted into the 

92 



TRANSPLANTATION OF THE ENTIRE FIBULA 

lower epiphysis of the tibia. The wound healed in two weeks. (See X-rays, Figs. 
7 and 8.) 

Functional result excellent twelve years following transplantation. 

Case IV. — C. W. M. Two years previous this man had a compound com- 
minuted fracture of both bones in the right lower leg, with the loss of two and 
one-half to three inches of bone. He had four operations. Examination on 
August 22, 192 1, showed a two and one-half inch gap at the junction of the 
middle and lower third of the tibia with a tendency to varus. The wound has 
since February, 1921, been healed. 

Diagnosis. — Non-union of old fracture of the tibia. 

August 26, 1921, lower end of the fibula transplanted into the lower end of 
the tibia. Wound healed in two weeks. (See X-ray, Fig. 9.) 

September 20, 1921, upper end of fibula transplanted into the upper end of 
the tibia. (See X-ray, Fig. 9.) 

December 28, 1921, lower fragment solid, upper fragment has slipped. To 
have another operation in two months. 

February 14, 1922, upper end of fibula placed in approximation with tibia and 
then sutured with kangaroo tendon. Convalescence thus far uneventful. (See 
X-ray, Fig. 9.) 

Clinically, one can see no reason why a perfect functional result should 
not follow. 

LITERATURE 

Campbell, W. C. 2 : Transference of the fibula as an adjunct to free bone graft 
in tibial deficiency. J. Orth. Surg., October, 1919, vol. i, pp. 625-631. 

Three cases are reported by the author. In order to make the success more 
certain in this condition, Campbell uses the following technic : An incision in the 
skin about four inches in length is made over the lateral aspect of the head of 
the fibula, the deep fascia is incised, then the capsule of the tibio-fibular joint. 
All cartilage and fibrous tissue is removed from the head of the fibula, being 
careful not to injure external popliteal or peroneal nerves. Next a cavity is made 
in the inferior and external aspect for the reception of the denuded head of the 
fibula. Heavy traction will place the head of the fibula within the cavity, provided 
scar tissue between tibial fragments does not prevent. When such difficulties arise 
these tough bands are excised or severed, the periosteum of the fibula is sewed 
to the periosteum of the tibia and the wound closed with catgut throughout. 
The final step is to do the inlay graft in the usual manner, which needs no 
description. This method has been successfully employed in the three cases. The 
advantages of the procedure are: 1st: It is possible to lengthen the limb one and 
one-quarter inches. 2nd : Early transference of head will stabilize limb and 
prevent shortening ; 3rd : At the end of eight weeks we have a stabile limb in 
which no false motion is possible between knee and ankle. 4th : Early stability 
prevents motion and facilitates the development of the free graft. 5th : New 
blood supply is added to the tibia through the medium of the fibula, promoting 
nutrition. 6th : Greater chances of complete success. One point that Campbell 
especially desires to emphasize is that a two-stage operation should be done in all 
cases where there is much difficulty in making the limb straight from contraction 
of dense scar tissue. Most patients will readily submit to the second operation 
when such marked improvement follows the first. 

C. J. Bond 3 : Transplantation of the fibula; osteomyelitis. Brit. J. Surg., vo'i. 
i, p. 610, April, 1914. 

Case I. — Little girl, aged four years. Shaft of right tibia had been destroyed 
by osteomyelitis in June, 1904. The right fibula was cut across just below the head 
of the bone and this portion, with the epiphysial cartilage, was left in normal 

93 



MacAUSLAND AND SARGENT 

position. The divided end of the shaft of the fibula was then pushed over to the 
inner side and inserted into the freshened lower surface of the tibial epiphysis, 
to which it was wired in position. 

Within the next two months firm, bony union had taken place. Bony out- 
growth took place from the isolated upper fragment of the fibula. The upper 
end of the shaft of the fibula began to assume the outline characteristic of the 
normal tibia. In March, 1907, fibula was divided just above external malleolus 
and lower end of shaft was displaced inward and inserted into soft cancellous 
tissues of the lower tibial extremity. The child now walks and runs with the 
aid of a high-soled boot without any noticeable limp. 

Case II. — A boy, in whom the shaft of the right tibia was destroyed by 
osteomyelitis in 1907. This was removed as a sequestrum in November of that 
year when the boy was ten years old. The place of the lost tibia was supplied by 
transplanting the shaft of the fibula in two stages, as in Case I. At the first 
operation, in March, 1908, the shaft of the bone was divided just below the head. 
It was then displaced inwards and the cut surface wired to the freshened 
tibial extremity somewhat to its outer edge. In May, 1908, the lower end of the 
shaft was divided above the external malleolus and embedded in the cancellous 
tissue of the lower tibial epiphysis. 

Owing to the contraction of the soft tissues of the limb, due to the absence 
of the tibial framework, considerable pressure was exerted on the lower end of the 
shaft and this gradually forced the end of the bone deeper into the spongy tissue 
until it eventually passed right through the epiphysis, almost passing through into 
the joint. Unfortunately, in this case, the disease affected the left tibia, destroying 
about two inches of the bone and producing a bad anterior posterior deformity 
of the limb at this spot ; about one and one-half inches of soft bone were removed 
and ends of divided shaft wired together. This necessitated a subperiosteal 
division of the fibula at the corresponding level. A year after the operation shows 
a restored shaft with a single central medullary canal and no callus. It is impos- 
sible from an examination of the limb on the skiagram to say that the fracture 
had occurred at this spot. 

H. Schloffer 4 : Zur Osteoplastik bei Def ekten der Tibia. Bruns. Beitr. zur 
klin. Chir., vol. xxv, 1899, p. 76. 

The transplantation of a graft from the fibula to the tibia was first prac- 
ticed by Hahn. 

Lilienthal writes of a wonderfully successful operation of this nature in a 
boy of nine years with absence of bony matter from the tibia due to fracture. 
The surgeon severed the fibula and fitted the upper end of the shaft into the tibial 
fragment. Within four months consolidation took place. McBurney simply 
sutured the head of the fibula to the tibia with favorable results. 

Gangolphe 5 : Considerations sur la resection du tibia pour osteosarcomes et sur 
l'utilisation du perone. Lyon Med., 1909, vol. cxiii, pp. 749-751- 

Patient suffering from suppurating tibia following fracture and which the 
author suspected of being an epithelioma. The author decided to make a large 
diaphyseal resection of the tibia, causing the patient to support his weight on 
the fibula. If the weight of the body does not exceed sixty kilometres this is 
possible. The author advises the use of the fibula of the other leg as, in case of 
some mishap in the operation, the patient stands more chance of recovery. The 
patient mentioned was operated on successfully by this method by another surgeon. 

M. Brandes 6 : Die Heilung grosster Tibiadef kte durch Transplantation. Med. 
klin. Berl., 1913, vol. ix, p. 1493. 

The author advises the use of the fibula of the same leg for transplantation 
because it is the material nearest at hand and, being usually strong and hypertrophic, 
is splendid material for bridging the tibial deficiency. The head of the fibula 

94 



TRANSPLANTATION OF THE ENTIRE FIBULA 

is split and the upper end of the fibular shaft implanted in the upper fragment of 
the tibia and then the lower end of the fibula is implanted in the lower fragment 
of the tibia. The result is a fusion of the tibia and fibula into a new bone formation 
which permits the movement of the leg. Two children, having undergone this 
operation, walk easily. 

Berard "' : Greffe d'une portion du perone gauche dans une perte de substance 
de ten cm. du tibia droite, consecutive a une fracture pathologique avec dystrophic 
osseuse. Lyon Chir., 1913, vol. ix, pp. 574-8. 

The patient, twenty-seven years old, had three successive fractures in the same 
place in seven years. The first two fractures consolidated normally. The third 
left the leg impotent, shortened by about three cm., curved slightly inward, and 
with pains. The author uncovered the tibial focus, which presented a swelling 
which had the appearance and consistency of an egg shell. 

In the interior of this cavity was a little serosanguineous liquid and some 
pimples forming an interrupted membrane. After ablation of the entire diseased 
bony area, the author realized a loss of bony tissue amounting to nine or ten cm. 
at the two poles of which the medullary canal was closed by a bony shell. The 
author then resorted to ablation of the left fibula, without its periosteum, to a 
length of twelve cm. The fragment of the fibula was inserted into the medullary 
canal of the tibial fragments. The operative results were uncomplicated. After 
five months the right leg was consolidated. The patient walked easily with a 
metal support. 

Lapeyre s : Autogreffe de la diaphyse peroneale pour remplacer la diaphyse 
tibiale necrosee et sequestree osteomyelite. Restauration du tibia autour de la 
greffe. Guerison avec resultat fonctionnel excellent. Bull, et Mem. de Soc. de 
Chir. de Paris, 1914, n.s. vol. xl, pp. 182-90. 

A child of three years came for treatment July 16, 1912, for an acute affection 
of the lower leg which had begun November 27, 191 1. Upon the author's first 
examination the tibia seemed in a necrotic state, which seemed to involve nearly 
the whole diaphyses. The upper and lower epiphyses were curetted and cleaned. 
Fifteen centimetres separated the two osseous extremities. Suppuration persisted. 
It was vain to hope for a spontaneous reparation. On February 2, 1913, the author 
performed the fibular transplantation. 

1. Careful curettage of the area to which the fibula was to be transplanted 
and extirpation of fungosities. 

2. The section of the fibula at its lower extremity. The length of the graft 
was about thirteen cm. 

The author did not dare to insert the two extremities of the fibula into the 
same epiphysis on account of the inflamed condition of the latter and decided to 
use two ivory pegs. For two or three months suppuration persisted at the upper 
end. At the end of three months consolidation was in progress. On September 
10th the leg appeared solid. It had taken seven months to obtain this result. From 
a radiograph taken on this date the transplanted fibula showed itself to be com- 
pletely surrounded by new bony tissue, irregular but solid. Suppuration had ceased. 
On December 10th, when the child left the hospital, he could walk with one cane. 
Thus transplantation of the fibula had saved a leg from amputation and recon- 
structed a useless member into a solid construction with splendid functional result. 

Michon 9 : Perte de substance du tibia, consecutive a une blessure par eclat 
d'obus ; transplantation du perone ; guerison avec bon resultat fonctionnel. Bull, 
et Memoires de la Societe de Chirurgie de Paris, vol. 422, 1916, pp. 1719-22. 

M. M. Sub-lieutenant, wounded by shell explosion on June 23, 1915, 
which resulted in a serious wound in the right leg. (1) A foot wound with tarsal 
fracture. (2) A fracture of the inner malleolus with a hole in the tibio-tarsal 
articulation. (3) A comminuted fracture of the medium tibia with important loss 

95 



MacAUSLAND AND SARGENT 

of bony substance covering about three cm. The limb was immobilized. The 
inferior wounds cicatrized after prolonged suppuration. The malleolar fracture 
was consolidated with tibio-tarsal ankylosis and a slight degree of equinism. On 
January 22, 1916, seven months after the accident, the author performed a 
transplantation of the fibula of the same leg, following the technic of Barbet. 

The operation consisted of the liberation and resection of the two tibial 
extremities by an internal incision and a section of the fibula by external incision. 
The fragment of the fibula, obtained by double section and adhering always to the 
interosseous membrane serving as pedicle, was thrust between these and the muscles 
of the anterior leg; the two extremities, bevelled, were both introduced into the 
medullary canal of the corresponding tibial fragment. The operation was long and 
tedious. The operative results were accompanied by suppuration and fever. The 
final results were satisfactory. 

The leg is solid. The grafting is surrounded by new bony matter according to 
radiographs. The lower fragment of the fibula was welded to the tibia. The 
upper fragment was loose but caused no discomfort. The patient could walk 
with a cane. 

P. Mauclaire 10 : Grosse perte de substance du tibia ; greffon emprunte au perone 
du cote oppose. Bull, et Mem. de Soc. Chir. de Paris, 1916, n.s. 12, 1864-66. 

Case of a soldier who was wounded by a bullet, leaving a large wound in the 
tibia. This produced an arterial aneurism, osteitis of the calcaneum and violent 
retraction of the Achillis tendon. The wound suppurated for a long period. Three 
months after cicatrization the author transplanted a graft from the fibula of the 
other leg. Above he sunk the graft into the medullary canal. Below he fastened 
it to the tibial groove with catgut. The author does not feel ready to advise the 
maximum length of bone to be taken for grafting. In the present case he used 
seven cm. of the fibula. In this patient the consolidation was rapid and the patient 
walks easily. The leg from which the graft was taken is in good condition. The 
tibia suffices by itself for the functions of the leg, if judged from the six cases 
of fibular grafts made by the author. 

For good consolidation it is necessary to sink the graft in the medullary canal 
as soon as possible. After the grafting the author sectioned the Achilles tendon 
to correct the equinism, then he scraped the necrotic calcaneum. The author states 
his intention of getting X-ray picture of this operation after one year has elapsed. 

Pierre Barbet " : Revue general de la reconstitution du tibia detruit par trans- 
position du perone voisin. La Clin. Par., vol. vii, 1912, pp. 65-69. 

It is evident that the Hahn-Huntington operation is beneficial. It furnishes 
almost certain results (showing only two partial failures in twenty-seven cases). 
From the functional standpoint it seems superior to other grafts. The cases show 
almost identical post-operative history: rapid consolidation, return of muscular 
vitality, progressive hypertrophy of the transplanted fibula. 

This operation is then preferred before all others. ( 1 ) In cases of destruction 
of the bony tissue due to osseous necrosis with death or insufficiency of regenerat- 
ing periosteum. (2) After periosteal resection of an osteosarcoma of the tibial 
diaphysis. (3) After resection of the foci of old pseudo-arthrosis, followed by 
fracture with atrophy of the fragments. 

Bond, C. J. 12 : On the .late results of three cases of transplantation of the fibula, 
with remarks on the process of growth and the physiological development of trans- 
planted bone. Brit. J. Surg., April, 1914, vol. i, pp. 610-624. 

Bond gives credit to Huntington as being the first surgeon to publish a case 
in which a successful attempt had been made to replace the whole shaft of the 
tibia by transplanting the shaft of the fibula into its place. The surgical results 
of the author's first two cases are as follows : The end results of bone transplan- 
tation in both cases (in one of which amputation had been suggested) Bond thinks 

96 








Fig. i. — Case I, A. B., taken April 12, 1916, before operation for transplantation of the 

fibula (A-P view). 



•** 



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Fig. 2. — Case I, A. L., lateral view taken April 12, 1916, before transplantation of fibula. 




Fig. 3. — Case IV, Mcralton. Radiogram taken five months following lower transplantation 
and one week following upper transplantation. 





Fig. 4. — Case I, A. L., post-operative radiogram, January, 1922. 




Fig. 5-— Case II, N. Y. 



V 




Fig. 6. — Case II, N. Y. Post-operative radiogram, taken January, 1922. 




Fig. 7. — Case III. L. B. Radiogram taken twelve years after operation. 




Fig. 8. — Case III, L. B. Radiogram taken twelve years after operation. 




Fig. 9.— Case IV, C. W. M. Showing transplant of fibula into tibia. 





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Tranjplanf'rro' Ti'hula. into TJbiH- 



Fig. io. — Diagrammatic sketch showing result of transplant. 



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TRANSPLANTATION OF THE ENTIRE FIBULA 

can be called satisfactory) . The functional result is good. Both children can 
walk and run well without assistance, one without any noticeable limp and the 
other with only a slight one. From the surgical point of view the problem is how 
to secure the continuous growth in length of transplanted shaft and how thus 
to prevent the shortening of the limb, which occurred in both these, as in other 
recorded cases. In regard to this question of stunted growth, no doubt, much will 
depend on the extent to which the disease which destroys the original shaft also 
damages the osteogenetic capacity of the epiphysial cartilages, especially the one 
which exercises the greatest influence on the growth of the leg bones. 

It was with the double object of restoring this capacity of bone formation to 
the damaged epiphysial cartilage and of counteracting the deformity of the limb 
caused by the unopposed growth of the fibula that Bond performed another 
operation on his third case. This case was a child aged four, who in 1903 
developed a tuberculous focus in the upper epiphysis of the left tibia which partly 
destroyed the epiphysial growing line. After abscess formation and recovery a 
considerable deformity was left and the limb was carried inwards at a sharp 
angle below the knee by the unopposed growth of the fibula on its outer side. 
In November, 1905, the left fibula was divided just below the head of the bone 
and this with the epiphysis was removed. A V-shaped portion of bone was then 
removed from the inner side of the head of the deformed tibia in the situation of 
the normal epiphysial junction. The deformity was then corrected by forcibly 
straightening the shaft of the bone. The removed head of the fibula was now 
cut down to a V-shape and was inserted into the wedge-shaped gap in the head 
of the tibia so formed and the wound was closed. The grafted cartilage healed 
well in its new position. The child now walks fairly well. There is, however, 
still some shortening of the limb and some internal rotation of the foot, showing 
that the growth of the tibia has not kept pace with that in the opposite limb. The 
author's first two cases showed no increased growth ; it made no attempt to take 
on new developments as long as it was connected with its own epiphyses, even 
though the tibia had been destroyed and it was exposed to new strains, but as soon 
as the shaft of this fibula became attached to tibial epiphyses, it began at once 
to assume a new outline and grow like the tibia. This fact suggests that it was 
the influence of osteoblasts from the tibial epiphyses which brought about the 
change and started the growth of the transplanted bone along tibial lines ; it being 
a fact that in Bond's, as well as in other cases, the transplanted fibular shaft did 
develop into a bone of the size and shape of the tibia, shows that the failure to do 
so in some cases is not due primarily to the fact that the transplanted bone is 
" naturally " a smaller bone, but to the fact that it is not sufficiently taken over, 
or its growth is not sufficiently stimulated, by osteoblasts of tibial origin. 

Torrance., Gaston 13 : Excision of the whole shaft of the tibia ; replaced by 
transplanting the fibula. Surg., Gyn. and Obst, Feb., 1912, vol. xiv, pp. 184-186. 

This case was a boy, six years of age, admitted to hospital May 15, 1908, with 
the history of having struck his right leg with a hammer over the middle of the 
tibia. An abscess formed at the point of injury, which was incised and curetted 
and healed up but reopened, and was operated again a few weeks later. Congenital 
syphilis was suspected, but no history could be elicited to confirm this. A con- 
siderable portion of the shaft had been chiseled out at different times, leaving a 
persistent sinus. When patient came under Torrance's care, about three months 
after admission, he was very much emaciated and ran a constant temperature. A 
skiagraph showed the tibia much enlarged and in an unhealthy condition. 

Excision of the tibia was proposed. Under ether an incision was made along 
the anterior border of the tibia and the bone was sawed in two with a Gigli saw, 
leaving about an inch of bone at either end; the shaft was removed without any 
attempt being made to preserve the periosteum ; the fibula was then sawed in two 

97 



MacAUSLAND AND SARGENT 

at the upper end and transplanted to the stump of the tibia and was held in place 
by suturing the muscles up snugly around it. The leg was placed in a wire splint. 
A skiagraph, made a week later, showed the fibula to be in good position. His 
general condition began to improve at once. He was allowed to be up on crutches 
at the end of four weeks and was in good physical condition. Two months after 
operation two large ulcers developed near the point of the original injury and 
grew larger and deeper under local treatment. 

He was put on potassium iodide and the dose rapidly increased to forty drops 
of the saturated solution, three times daily. He bore this treatment well and the 
ulcers healed rapidly. On questioning the father again he admitted that the child 
had contracted syphilis from kissing a relative at two years of age and had been 
treated for about a year. A skiagraph, made five months after operation, showed 
that the fibula had about doubled in size and that the union with the tibia was 
rounded off, resembling a joint "wiped" by a plumber. A few weeks later he 
was walking on the limb without a splint or crutch; the only difficulty he experi- 
enced was a slight tilting of the ankle. The lower end of the fibula was trans- 
planted ten months after the first operation. He was allowed to walk about on 
crutches for two months and then lateral splints were applied and he was allowed 
to put some weight on the leg. 

He was again seen in August, 191 1, when a photograph and the last skiagraph 
was made. The muscles of the leg are well developed and there is no shortening; 
while the skiagraph shows some bowing of the shaft, the general lines of the leg 
are almost perfect and when standing with long stockings on it is not possible to 
tell which is the operated leg. He runs, jumps and plays with the other children 
and has perfect use of the leg. 

T. W. Huntington 14 : Case of bone transference. Use of a segment of fibula 
to supply a defect in the tibia. Annals of Surgery, February, 1905, vol. xli, 
pp. 249-251. 

Huntington's case illustrates the possibility of supplying a tibial defect 
amounting to absence of nearly the entire diaphysis by the appropriation of corre- 
sponding portion of the fibula. The early history of the case is that of an acute, 
infectious osteomyelitis of the left tibia. The patient, a boy of seven, entered the 
hospital in May, 1902. The trouble began a few days before. While at play he 
sustained a slight injury to the left leg just below the knee. Leg became swollen, 
tense and acutely tender. There was high temperature succeeding a chill. The 
attending physician made a small incision about three inches below the knee, from 
which, at time of admission, there flowed a small amount of clear yellow fluid. 
Tibia was extensively denuded and near the ankle there were two red fluctuating 
areas. An incision along the spine of the tibia from the tubercle to one inch 
above the ankle-joint revealed the fact that nearly the entire shaft was disinte- 
grated. Pus oozed through several sinuses leading to the medullary cavity. 
On stripping the periosteum, the cortical portion of bone was readily scooped 
out with a curette, leaving a trough of periosteum. Having in mind the possi- 
bility of bone reproduction, the periosteum was stitched into a tube of small 
calibre. The wound was drained, partly closed and the leg laid upon a posterior 
splint. For three months there was gradual and satisfactory progress and the 
wound was fully healed. Six months later, despite an apparent effort on the 
part of nature to reproduce the tibia, there was still an interval of about five 
inches between the upper and lower fragments and progress here seemed to be 
practically suspended. The leg could not be extended upon the thigh, but hung 
loose, flail-like, and utterly useless. On January 27, 1903, Huntington finally 
determined to supply the defect by sawing the fibula at a point opposite the lower 
end of the upper tibial fragment and attaching it thereto. This was done without 

98 



TRANSPLANTATION OF THE ENTIRE FIBULA 

difficulty and the divided end of the fibula was firmly planted in a cup-shaped 
depression in the tibia. 

At this time the diameter of the fibula was about that of an ordinary lead- 
pencil. Union was tolerably slow but solidification was finally noted six months 
later. In September, 1903, the lad walked with the limb encased in two lateral 
splints as a support to the ankle-joint, there being a tendency for the foot to evert 
when the patient stands upon the affected member. Not satisfied, Huntington 
concluded to transfer the lower end of the fibula to the lower fragment of the 
tibia, which was done October 6, 1903. The wound healed kindly and on 
February 15, 1904, perfect bony union was secured. Since that time the patient 
has progressed admirably. The limb, though three-quarters of an inch short, has 
assumed the dimensions and in a general way the contour of the normal member. 
The transferred portion of the fibula shows that its diameter is now three-quarters 
of an inch, or practically the same as the opposite tibia. The lad joins in the 
ordinary sports of other boys and, despite the lateral deformity and slight shorten- 
ing, he walks without support and with only the suggestion of a limp. In a 
similar case Huntington would insist upon the affected member being kept at rest 
until the second transposition could be effected ; thereby avoiding the deformity, 
which is the only serious defect in this case. Considering the extensive destruc- 
tion of the tibia which occurred before patient was seen by the author, he 
can conceive of no other method which would have offered a result so satisfactory 
as the one adopted. 

J. S. Stone 1o : Partial loss of the tibia replaced by transfer of the fibula, with 
maintenance of malleoli of the ankle. Annals of Surgery, October, 1907, vol. 
xlvi, pp. 628-632. 

The author's case was a boy five years old, who in June, 1904, had an acute 
dissecting periostitis beginning at the lower end of the right tibia and in six days 
stripping the bone nearly as far as the patellar tubercle. Owing to sloughing of 
the periosteum after removal of the shaft the tibia regenerated very imperfectly. 
Nine months after the onset of the trouble the bone had reformed for about one 
and one-quarter inches from the upper end. There was then a gap of about an 
inch. The fibula was normal. Thirteen months after the onset of the trouble 
he was admitted for operation. Since ten weeks after the trouble began he had 
been going about with a plaster bandage and Thomas knee-splint. The attach- 
ment of the upper end of the fibula had become loose so that the head of the bone 
could be shoved upward slightly and the foot moved inward for about two and 
one-half inches. There was marked shortening of the leg and the foot was a 
little smaller than on the sound side. The fibula had become somewhat hyper- 
trophied, particularly at the middle of the shaft. All wounds were healed. 

It was decided to transfer the fibula into the gap in the tibia. The upper 
end was transferred first. A vertical incision about three inches long was made 
directly over the lower end of the upper sound portion of the tibia. The cut 
was made directly through the periosteum which was separated on the fibular side 
for a vertical distance of about two inches. In order to reach the fibula more 
readily a second incision of one and one-half inches long was made directly down 
onto the bone on the outside of the leg. At about two inches from the upper 
end the fibula was then cut across with a chain saw. The upper end of the lower 
fragment was then inserted into a mortise cut in the tibia. The periosteum was 
reflected from that side of the fibula which rested in the mortise. The reflected 
periosteum of tibia and fibula were then sutured together with chromic catgut 
to maintain close apposition and the reflected periosteum of the tibia was further 
sutured as a cuff around the upper end of the fibula to hold it more securely in 
position. The incisions were closed with drainage. A sterile dressing and plaster 
bandage were applied. The boy was readmitted to the hospital five months after- 

99 



MacAUSLAND AND SARGENT 

wards. The union between the upper end of the tibia and the fibula had become 
absolutely solid and the shaft of the fibula had materially increased in thickness. 
Five and a half months after the first operation a longitudinal incision was made 
anteriorly over the outer part of the lower end of the tibia. The bone was 
exposed. By careful dissection the lower end of the fibula was then exposed 
through the same incision and split horizontally with a chisel for a distance nearly 
four inches. A small pocket was cut in the cartilage covering the end of the tibial 
epiphysis just large enough to receive the inner half of the fibula. 

The inner half of the fibula was then sprung into its new position in the tibia. 
Closure was made without drainage. A plaster bandage from the toes to the 
thigh completed the dressing. Three months later plaster was removed. A small 
granulating spot was found at the lower end of incision. Bony union was solid. 
Five days later a small piece of necrotic bone about three-quarters inch long 
was discharged. After this the skin healed solidly. A month later the boy began 
to walk on his leg, and ever since has used it without restraint. The problem 
presented in this case was the restoration to usefulness of a leg in which the fibula 
was sound, the upper end of the fibula was sound and in which the lower epiphysis 
of the tibia remained, but without any shaft for a distance of nearly five inches. 
The continued increase in the size of the transferred bone is most striking and 
corresponded in amount with the freedom of use which was allowed. In any 
similar case more prompt transfer of the bone would seem advisable. The length 
of time allowed between the steps of the operation might also have been shortened. 

A. Keith 18 : Fibula transplantation to replace the necrosed shaft of the tibia. 
Menders of the Maimed. London, 1919, p. 273. 

Keith states that the most instructive examples of bone transplantation are 
those in which the fibula has been used to replace the necrosed shaft of the tibia. 
The case he wishes to call attention to is that of Bond (Brit. J. Surg., 1914, vol. 
i, p. 610), who operated in May, 1905. He also cites Professor Huntington as 
having carried out the first successful substitution of fibula for tibia, publishing 
an account of it in 1905 (Annals of Surgery, 1905, vol. xli, p. 249). The same 
problem had presented itself to two men situated on opposite sides of the earth and 
both had adopted the same method of solving it. 

BIBLIOGRAPHY 

X W. Russell MacAusland: Surg., Gyn. and Obst, April, 1912. 
J W. C. Campbell : J. Orthop. Surg., vol. i, p. 625, Oct., 1919. 

3 C. J. Bond : Brit. J. Surg., vol. i, p. 610, Apr., 1914. 

4 H. Schloffer : Bruns. Beite. zur clin. Chir., vol. xxv, 1899, p. 76. 
5 Gangolphe: Lyon Med., 1909, vol. cxiii, pp. 749-751. 

8 M. Brandes: Med. klin. Berl., 1913, vol. ix, p. 1493. 

7 M. Berard: Lyon Chir., 1913, vol. ix, pp. 574-8. 

8 L. Lapeyre : Bull, et Mem. de Soc. de Chir. de Paris, 1914, n.s. vol. xl, pp. 182-90. 
Ed. Michon : Bull, et Memoires de la Societe de Chirurgie de Paris, vol. 422, 1916, 

pp. 1719-22. 

10 P. Mauclaire : Bull, et Mem. de soc. Chir. de Paris, 1916, n.s. 12, pp. 1864-66. 

11 Pierre Barbet : La Clin. Par., vol. vii, 1912, pp. 65-69. 

12 C. J. Bond: Brit. J. Surg., April, 1914, vol. i, pp. 610-624. 

18 Gaston Torrance : Surg., Gyn. and Obst., Feb., 1912, vol. xiv, pp. 184-186. 
U T. W. Huntington: Annals of Surgery, Feb., 1905, vol. xli, pp. 249-251. 
18 J. S. Stone : Annals of Surgery, October, 1907, vol. xlvi, pp. 628-632. 
* A. Keith: Menders of the Maimed. London, 1919, p. 273. 



100 



» 



\/ 



Reprinted from the New York State Journal of Medicine, September, 1923 



ANKYLOSIS; TREATMENT BY 
ARTHROPLASTY.* 

By W. RUSSELL MacAUSLAND, M.D., 

BOSTON, MASS. 

INJURY to the smooth resilient cartilage which 
lines the normal joint, whether due to disease 
or external violence, results in a lessened range 
of motion, and, if severe enough, in complete loss 
of motion. A bony bridge, or fibrous tissue de- 
velops and may entirely replace the joint space, 
giving rise to bony or fibrous ankylosis. 

Ankylosis of a joint causes varying degrees of 
disability, depending (1) on the joint involved, 
(2) on the stabiltiy of the ankylosis, and (3) 
on the deformity present. For instance (1) 
loss .of motion in a spinal joint may take 
place without the individual's being aware that 
he has lost any function. This observation 
is frequently made in chronic arthritic cases. 
Occasionally a striking loss of motion may be m 
observed in the whole lumbar spine without the 
patient's being aware that function has been 
lost. A wrist joint may be stiff with only the 
slightest disability. One knee joint without mo- 
tion may be disabling only in a mild degree. The 
second factor, (2) stability, must be kept con- 
stantly in mind. To return to the example of 
the stiff knee joint — the disability and pain may 
be considerable if there is a fibrous ankylosis 
which is susceptible to joint strain; on the other 
hand, if the ankylosis is bony, the patient may 
suffer no pain and only slight disability. It is 
in weight-bearing joints that this factor is of 
more importance. 

(3) There is a direct relation between the de- 
formity present and the amount of disability in 
most joints, and it is with this factor more than 
any other that the surgeon must deal. A hip 
joint with flexion and adduction deformity may 
be very disabling, but if the hip is ankylosed in a 
good position, there is little loss of function. 
Similarly, a shoulder joint ankylosed with the 
proper degree of abduction may show a range of 
usefulness which closely approaches normal. 

It is important for the surgeon to be familiar 
with these facts concerning ankylosis, before he 
approaches the subject of arthroplasty, or the 
mobilization of ankylosed joints by operation. 
Each individual case must be considered singly 
and not infrequently the surgeon must base his 
final decision upon a minor factor, which without 
careful consideration might be overlooked. It is 
not merely the fact that the joint is stiff that leads 
one to advise operation. 

Indications for Arthroplasty. 

What may be considered, then, the definite in- 
dications for operation? In general, only cer- 
tain joints are to be considered for operation, 
and these in the following order of frequency: 



* Read at the Annual Meeting of the Medical Society of the 
State of New York at New York City, May 23, 1923. 



(1) the elbow, (2) the ^ hip, (3) the knee, (4) 
the temporo-maxillary (jaw), (5) the wrist and 
fingers. Other joints are not included for the 
reason that the ankylosed joint in good position 
will give good function. The shoulder, as has 
been mentioned before, functions well in a good 
position. The ankle stiff at a right angle func- 
tions well. Further indications for mobilization 
should be considered for each separate joint 
which I shall take up in order. 

(1) The elbow — 

(a) When both elbows are stiff, arthroplasty 
is always indicated on one joint, at least. 

(b) Arthoplasty is always indicated when the 
loss of function in the joint is a serious disability 
in a patient's occupation. 

(c) Arthroplasty is indicated when the elbow 
is stiff in a bad position. By this, I mean that if 
an elbow is stiff at 180°, it is absolutely necessary 
to change the position for functional purposes 
and, since an operation is required to do this, the 
procedure may well be an attempt to mobilize 
rather than a simple osteotomy. 

(2) The hip— 

(a) Two s^iff hips may be considered a defi- 
nite indication for an attempt to mobilize one of 
them. 

(b) A stiff hip associated with a stiff knee in 
either leg may be considered a definite indication 
for mobilization. 

(c) A stiff hip in bad position requiring an 
osteotomy rarely may be considered an indication 
for arthroplasty. 

(3) The knee — 

(a) Two stiff knees alone or associated with 
one or two stiff hips may be considered an indi- 
cation for an attempt at mobilization of one and 
rarely both knees. 

(4) Temporo-maxillary — Always must be mo- 
bilized. 

(5) Wrist and fingers — 

(a) The general indications for arthroplasty 
are rare because of the fact that in hyperexten- 
sjon a stiff wrist causes very little loss of func- 
tion. For patients who require wrist-joint mo- 
tion in their work, an attempt at arthroplasty is 
permissible, but the procedure is rarely found 
necessary. In finger joints, also, operation is 
seldom applicable, and the judgment of the sur- 
geon depends solely on the patient's individual 
circumstances. 

CONTRA-INDICATIONS TO ARTHROPLASTY. 

(1) The tubercular joint rarely, if ever, lends 
itself properly to operative interference. 

(2) No joint should be mobilized in which a 
stiff joint is of slight disability. 

(3) No joint should be mobilized when opera- 
tion is contra-indicated by age or the patient's 
general condition. 



A Short History of the Mobilization 
of Joints. 

The mobilization of stiff joints was first at- 
tempted by J. Rhea Barton in Philadelphia in 
1826, who produced a pseudo-arthrosis in a case 
of ankylosis of the hip joint. From this time 
many writers who have advocated various meth- 
ods have written on this subject. The great ad- 
vances in the work have been due to such men as 
the late Dr. John B. Murphy of Chicago, Dr. Putti 
of Bologna, Dr. Baer of Baltimore and Dr. Neff 
of Chicago. By the untiring and earnest efforts of 
these leaders much has been done to advance this 
work and to so stabilize surgical technique in its 
application to ankylosed joints that, at the present 
time, the surgeon who is devoting his attention to 
this special branch may justifiably and without 
hesitation recommend arthroplastic measures in 
certain joints. Various substances have been 
advocated as interposing material ; fat, muscle, 
fascia, and specially prepared membranes. The 
concensus of opinion, however, is that free fascia 
transplants give us the best and most consistent 
results. 

Arthroplasty not an Excision. 

It is necessary to point out quite definitely the 
difference between arthroplasty and excision. 
Literature is filled with various reports of cases 
in which the procedure, an excision, resulted in 
the unstable joint that one expects from a care- 
less removal of bone. Excision does not result in 
stability; arthroplasty does. Excision is a crude 
surgical procedure, the ultimate results of which 
do not warrant its use in any conditions save in 
serious joint infections, usually of tubercular 
origin. 

A good arthroplasty gives a good sliding joint. 
The late Dr. John B. Murphy has emphasized 
this point over and over again. The range of 
motion in the joint is always good and its 
strength approaches normal. Stability is an ab- 
solute essential. The joint should also be pain- 
less and able to stand hard use without showing 
arthritic changes. To summarize : An arthro- 
plasty results in good permanent motion, good 
strength, and good stability, without pain. 

Technique for Arthroplasty. 
In the technique for arthroplasty for various 
joints, the approach and exposure to enable 
proper remodeling of the joint, as well as the 
proper interposition of tissue, seem to me to be 
the two fundamental factors to be considered. 
With these in view, the following technique for 
elbow-joint arthroplasties has been evolved. It 
will be readily seen that the posterior exposure 
has many advantages over the double lateral ex- 
posure, in that perfect remodeling and interposi- 
tion of tissue may be obtained. 

Operative Technique. 

The Elbow Joint — 

The arm from the wrist to the shoulder and 
the leg on the same side, from the hip to the knee, 
are given a two-day preparation. At the time of 



the operation, a tourniquet is applied to the upper 
third of the arm and an application of iodine made 
to the skin. 

A semicircular incision is then made, beginning 
over the external condyle and running down 
about two inches and up over the internal con- 
dyle. The wound is sponged with alcohol and 
carefully clamped off to avoid the handling of the 
skin during the operation. The flap containing 
skin and superficial fascia is then dissected back 
to the base line and retracted. The ulnar nerve 
is isolated and dissected out of its sheath. It is 
sometimes difficult to find this nerve, but it is 
always to be sought at the inner side of the in- 
ternal condyle. It should be dissected out care- 
fully with a blunt dissector so as not to break or 
injure it. After it has been freed for one and 
one-half inches, gauze is passed beneath the nerve, 
and it is retracted to the ulnar side. It is then 
freed further by blunt dissection with gauze. 

A transverse incision is then made extending 
down through the periosteum. This incision fol- 
lows in direction the superficial one, and outlines 
a flap which is to be dissected back and preserved 
in toto for subsequent covering for the joint. 
The pulling back of this flap is a hard and tedious 
process until it is well started, after which it can 
be peeled back readily by blunt dissection. It is 
the inner side that is the hard part, as the layer is 
thin here, and one must exercise great care not to 
buttonhole it. The olecranon is then sawed 
through. After this, it is frequently possible to 
break open the old joint. In some cases, however, 
ankylosis is bony and the joint cavity obliterated. 
Cases of this kind are the most difficult and in 
these it is necessary to saw through the joint. 
The tip of the olecranon has to be chiseled out and 
dissected back with its posterior flap. Usually 
the olecranon is too large, and it is well to take 
off a little of it. 

The capsule, fascia, and ligaments are then dis- 
sected back so as to allow the lower end of the 
humerus to protrude into the wound. Then its 
edges are snipped off with rongeur forceps and a 
new trochlear or intercondylar surface formed. 
A shoemaker's rasp is used in filing the extremity 
as near like the normal humeral end as possible. 
After this modeling, a piece is removed cor- 
responding to the olecranon fossa in the normal 
humerus. One has to be careful about making 
this cup, as the success of the operation depends 
largely upon attention to such small details. This 
modeling is largely done with a saw and a file. 

To ensure good function, the joint surfaces 
should fit accurately before the fascia is applied, 
but the joint should not be too loose. Only suf- 
ficient bone must be removed to give free motion. 
If too much bone is removed from the ends, 
a flail joint will result, giving the operation no 
advantage over an excision. When this mortising 
is completed, the fascial flap is dissected from the 
leg. An incision is made on the outer side of the 
thigh, a little below the middle, extending down 
to the fascia lata. After a flap of fascia five to 



seven inches by four to five inches is dissected 
out, the wound is closed. 

This fascia, which is free from all fat, is placed 
about the newly fashioned humeral condyles and 
attached anteriorly to the capsule and posteriorly 
to the periosteum of the lower end of the shaft of 
the humerus with interrupted chromic catgut 
sutures No. 2. Chromic catgut No. 2 is then 
loosely wound twice around the shaft just below 
the interrupted suture line. . 

The forearm is placed in apposition to the 
condyles. Two drill holes are then made in the 
olecranon process and two others opposite them 
in the shaft of the ulna. Through these, kanga- 
roo tendon is passed and tied. The inner layer 
is now sutured with chromic catgut No. 2 and the 
skin and fascia with plain catgut No. 2. Dry 
sterile dressings are applied and the arm put up 
in plaster beyond a right angle. 

After-treatment. 

If there is no evidence of infection, the cast 
should remain on for a week. It is then split and 
the dressing changed. If there is a persistent 
temperature, a window should be cut in the cast 
and the wound inspected. 

If normal healing takes place, passive mo- 
tions are begun in about ten days. The arm is 
always kept above a right angle. After three 
weeks, gentle massage is applied. Baking is be- 
gun in six weeks and practised three or four 
times a week. 

The ultimate success in these cases depends 
very largely on the after-treatment. The patients 
should be under observation for a long period of 
time. Frequent X-Rays should be taken so that 
we may follow the bony changes in the joint. If 
motion begins to shut down, the arm should be 
manipulated under an anaesthetic and the elbow 
put up in acute flexion. Occasionally motion be- 
comes limited, due to an exuberant growth of new 
bone. In this case, a secondary operation should 
be done to remove the new bone, but it should not 
be undertaken for at least three months after the 
original operation. 

Case I. W. D. was referred to me by Dr. 
A. W. Shea of Nashua, New Hampshire, and 
was operated on before the New Hampshire 
Surgical Club. On March 25, 1911, he had re- 
ceived a contused wound of the left thumb, which 
became septic. Sepsis became general and in a 
week he entered the hospital. Five incisions were 
made in the left hand, two in the left wrist, one 
close to the left elbow-joint and one in the left 
hip. All had drains put in. A student in the 
hospital opened a swelling near the right elbow 
and cut into the joint. At the end of twenty-one 
weeks the patient was discharged from the hos- 
pital with bony ankylosis of the right elbow and 
with only a few degrees of motion in the left 
elbow. Both joints were slightly flexed. The 
left wrist had a sinus which still drained a little. 
The patient had little motion in the fingers, being 
unable to flex them to a right angle with the palm 



of the hand. He was unable to feed himself or 
to touch his head with either hand. 

He entered St. Joseph's Hospital, and I did an 
arthroplasty on the right elbow, in March, 1912, 
using a flap of fascia lata for interposition. A 
hard bony ankylosis Was found. The skin was 
closed with silkworm-gut and a voluminous 
dressing applied with the arm at a right angle. 
Arm and forearm were placed on pillows with 
heavy dressings but no splint. Passive motion 
was begun on the fifth day. Primary union took 
place in the wounds of the elbow and thigh. 
Passive motions were continued and increased, 
but at the end of six weeks it was found that he 
could not use either biceps or triceps muscles, as 
he had lost all power from long disuse. However, 
after several weeks he trained the muscles by 
counting and attempting contraction at the same 
time. Finally he was able to flex the forearm 
himself, and since that time improvement has 
continued. 

He has now full motion in flexion, extension, 
and rotation, and is able to feed himself, put on 
his own clothes, and to do chores about the house. 





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Fig. 1, Case I, W. D. Ankylosis elbow. Six months 
after operation, showing voluntary flexion and exten- 
sion and power of biceps. 



Previous to the operation, he was entirely help- 
less, and unable to care for himself in any way. 
Case II. W. D. The previous history of this 
case is given under Case I. After the arthroplasty 
on the right elbow, the patient requested that a 
similar operation be done on the left elbow. The 
roentgenogram showed a bony ankylosis at 90°. 
On January 31, 1914, I did an arthroplasty on the 
elbow, using the same method as applied on the 



right elbow. The end-result was a stable useful 
elbow, with motion from 60° to 160°. 

Case III. I. H. had fallen on her elbow four 
months before she entered the hospital. She had 
suffered considerably from pain and was unable 
to use her arm. At this time, I manipulated her 
elbow under ether and later manipulated it every 
two weeks in the Carney out-patient department. 
On account of the limitation in motion, an arthro- 
plasty was advised. 

She entered the Carney Hospital on June 22, 
1915. At this time, the elbow was slightly tender 
and motion was limited to 40°. There was no 




Fig. 2, Case II, I. H. Ankylosis of elbow, showing 
voluntary motion in flexion and extension, eight months 
after operation. 

pain, but the joint was somewhat enlarged and 
the bones felt rough. The roentgenogram showed 
an old fracture of the lower end of the humerus. 
On June 23d, I did an arthroplasty of the elbow- 
joint, using a free flap of fascia lata. The patient 
made a good ether recovery. The following day, 
the plaster was trimmed about the fingers. The 
fever and swelling of the hand continued for sev- 
eral days until, on the 28th, after the cast was 
bivalved, the temperature dropped and the oedema 
disappeared. 

On July 3d, the patient was up in a chair. On 
the 6th, the dressing showed a slight superficial 
sepsis. The motion of the arm was very much 
increased. She was discharged from the hospital 
on July 15th to report to the out-patient depart- 
ment. There was a gradual return of motion. 

Case IV. W. M. had fractured his olecranon 
as the result of a fall. After an open operation 
in which the olecranon was fastened in place with 
silver wire, the elbow gave him no further trouble 
until a year later following a second injury. A 
box had fallen and hit him on the elbow. Two 
weeks later, when he reported to the hospital, he 
was in great pain and showed a discharging sinus 
from which a piece of wire, which was protrud- 
ing, was easily removed. Free drainage was 
established and later the arm was twice curetted. 

He was discharged March 21st after a 
tempestuous illness, to report to the out-patient 
department for dressings. In July the wounds 
had healed and the patient was discharged to re- 
turn in six months for an arthroplasty. 

This I did on July 9, 1919, and on his discharge 
from the hospital on September 4th, he was able 
to flex and rotate his arm voluntarily. On October 



18, 1919, he had voluntarily motion from 158° to 
105°. On October 30, 1920, he had voluntary 
motion from 60° to 135°. 

Case V. E. M. The patient's trouble started 
slowly with general poor health. Two years ago, 
she became ill with infectious arthritis, which at 
first affected the knees. There was no history 
of a neisserian infection. The patient was very 
much constipated and suffered more or less from 
tonsillitis. Later, the elbows became painful and 
could not be straightened out. 

Physical examination showed a thickening of 
the capsule of the left elbow, with about 35° 
limitation in motion. The left knee showed ex- 
tension to within 15° of full extension. The 
patient walked with a marked limp, and flexed 
knees. General treatment, was prescribed, with 
forcible extension of the knees. As motion in the 
arm had shut down, leaving it ankylosed at 100°, 
an arthroplasty on this joint was advised. 

February 25, 1913, I did an arthroplasty, using 
my fascia lata method. 

March 24, 1913, the arm showed no swellings. 
There was little pain, and the patient's general 
condition was fair. There was about 15° mo- 
tion. Gentle manipulation was ordered. 

December 16, 1913, the wound had healed by 
first intention ; supination was three-quarters nor- 
mal, extension was possible to 170° and flexion 
to 10° to 15° beyond a right angle. The patient 
could reach the opposite shoulder with the thumb 
with ease, but could not dress the lower part of 
the hair. The muscular power was as good as in 
the right arm. To gain more motion, a forcible 
manipulation was advised. 

December 29, 1913, under ether, extension to 
within 5° of straight was obtained and flexion 
to 45°. 

January 26, 1914, examination of the arm 
showed no lateral mobility and no crunching 
crepitation. Mobility was possible from 150° to 
70°. 

B AC 





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Fig. 3, Case V, E. M. End-result, ten months after 
arthroplasty. 

A. Voluntary flexion. 

B. Voluntary extension. 

C. Range of motion (not full motion). 

Case VI. S. S. This patient was first admit- 
ted to the Burbank Hospital, Fitchburg, December 
5, 1917, with a subacute neisserian infection. 
Five years previously the right knee had become 
swollen and remained so for three months. A 
month later, the right elbow became swollen and 
painful. The Wassermann test was positive. 



She remained in the hospital thirty-eight days, 
receiving general treatment and was discharged 
relieved. 

She returned to the out-patient department, 
July 1, 1918. The arm was then put in plaster 
from wrist to shoulder, to remain on two months. 
She was told that her elbow would probably be- 
come stiff and would require an arthroplasty later. 

On January 9, 1919, the patient was advised 
to have an arthroplasty done, as her elbow had 
become stiff. Following the operation on Febru- 
ary 6th, she had an uneventful recovery. The cast 



January 11, 1911, about 30° to 40° motion in 
flexion and extension were obtained. The wound 
showed heavy granulated tissue- A week later 
she was discharged from the hospital. Dressings 
were to be done at home. 

February 28, 1911, she was re-admitted to the 
hospital for manipulation. Normal motion was 
obtained. Since this time, she has been seen in 
the out-patient department. There is practically 
no lateral mobility and the end-result is perfect 
function. 




Fig. 4, Case VI, S. S. End-result, three months after 
arthroplasty. 

At left, voluntary flexion. 
At right, voluntary extension. 

was removed in two weeks, after which passive 
motion was begun. She was discharged March 
18, 1919. 

Case VII. M. R. For thirteen years this 
patient had had attacks of rheumatism affecting 
the ankles, elbows, and knees. The physical ex- 
amination was negative except for the joints. 
Both knees were slightly flexed and the right one 
was ankylosed, showing scars on either side. The 
right ankle showed some contraction of the tendo- 
achillis. The left elbow showed good motion 
except for 10° limitation in extension; the right 
was ankylosed at 125°. 

The patient was admitted to the orthopedic 
service of the Carney Hospital, September 6, 
1910, where very slight improvement took place in 
the knees and feet under conservative treatment. 
In October, 1910, on account of the swelling and 
bogginess of the left knee, an arthrotomy was ad- 
vised. This was done October 19, 1910. Daily 
manipulations were begun on the fifth day, and 
an uneventful recovery took place as regards the 
knee. 

As the elbow was stiff and in an ungainly po- 
sition, operation on this joint was advised. On 
November 5, 1910, an arthroplasty by the Murphy 
method was done on this joint. 

November 10, 1910, the right hand was consid- 
erably swollen and painful, for which pressure 
and hot fomentations were applied. The skin on 
the upper part of the arm became somewhat 
necrotic from poor circulation and later sloughed. 

November 30, 1910, passive motion was begun 
and repeated daily. The first attempt at motion 
was made and 30° attained. Progress was con- 
tinuous and a gradual gain in motion was made. 
Later, massage was ordered for the hand, fore- 
arm, and shoulder. 




Fig. 5, Case VII, M. R. End-result, fourteen months 
after arthroplasty. 

A. Voluntary flexion. 

B. Voluntary extension. 

C. Range of motion. 

The Knee Joint. 

Knee-joint technique, I feel, has been perfected 
to its highest degree by Putti. My technique dif- 
fers, in that division of the patellar tendon or 
elevation of the tibial tubercle with the patella is 
not done, as these seriously complicate conva- 
lescence. The Kocher incision is used and the 
joint exposed and remodeled in the following 
manner : 

Operative Technique. 

The usual preparation is given both legs from 
the ankle to the groin. I feel it is best to remove 
the fascia from the opposite leg, thereby minimiz- 
ing the extent of the operation on the ankylosed 
leg as well as making it possible to remove more 
fascia without disturbing the external support 
of the joint. 

The incision is made ftom just below the inner 
attachment of the patella tendon, curving slowly 
over this point to the middle of the external 
cartilage, and then directly up the outer side of 



the leg just above the mid-horizontal line, a dis- 
tance of five to ten inches from the joint proper. 
As much fat as possible is taken with this incision. 
After clamping the skin-edges with towels, the 
skin is dissected to the inner side of the leg, ex- 
posing the patella tendon, patella, and tibial 
tubercle. 

A curved incision is then made through the 
fascia, beginning in the mid-anterior line, about 
five inches above the patella, and running be- 
tween the patella and outer condyle to just below 
the knee-joint. 

The quadriceps tendon is then exposed and 
elongated. This elongation not only allows better 
joint exposure, but affords a proper lengthening 
when we later place the leg in flexion in plaster. 
This lengthening may also be done by the Ben- 
net method. The patella is then raised from the 
femur, taking the lower cut portion of the quadri- 
ceps tendon, and forcibly retracted to the inner 
side of the knee, with its inner ligament attach- 
ments intact. Some surgeons detach a piece of the 
tibial tubercle in order to increase exposure, but I 
have found this unnecessary when the quadriceps 
tendon is elongated in the beginning. There are 
also many difficulties when this piece is removed, 
such as delayed or faulty union, which complicate 
the convalescence. 

The patella in these cases is often found hyper- 
trophied and should be narrowed laterally, as well 
as thinned and smoothed with a shoemaker's rasp. 

The joint being then exposed, a careful study 
of it is made from X-Rays, and great care is taken 
to follow the contour carefully. Putti instru- 
ments are admirable for this purpose. 

Several important requirements must be ob- 
served: 

1. Be sure to leave a well-defined spine between 
the tibia condyle, as well as cupping out the upper 
tibia surface, which will help stabilize lateral 
mobility. 

2. Carefully round the condyle with a Putti 
instrument and a shoemaker's rasp, making a con- 
cavity to fit over the newly formed spine. 

3. Actually replace these opposing surfaces, 
and mould carefully, without any irregular 
hitches during attempts to flex. 

4. Cup out a space into which the patella will 
articulate. Great care should be taken with this 
modeling. 

5. Remove a large piece of fascia lata ample 
enough to cover both condyles. The fascia near- 
est the knee on the outer side is thickest and most 
serviceable. When this is removed, sew the 
fascia over the condyle, covering all exposed bone 
well. Sew posteriorly two inches above the 
articular surface. The femur is then adjusted to 
the tibia and the patella is replaced. The outer 
fascia is united with interrupted chromic catgut. 

The elongated quadriceps is then strongly su- 
tured and the skin closed with interrupted catgut. 
A plaster is applied from the toe to the groin with 
the knee in 35° to 40° flexion and the leg placed 
in an elevated position in bed. Opiates are often 
necessary and may be freely used. 



After-treatment. 

The temperature, pulse, and pain are carefully 
watched for any signs of infection. 

The cast is split for dressing in two weeks and 
the leg placed into a ring caliper with 35° flexion, 
so arranged that this can be changed and passive 
motion slowly started. 

Traction is also applied with this caliper which 
remains on day and night. 

Gentle passive motions are started and in- 
creased gently, guided by pain and sensitiveness, 
which always should be minimized. 

Massage is started in five to six weeks for thigh 
and calf, and the patient may usually walk with 
crutches about the sixth week. 

By means of an overhead extension, the patient 
may also use passive motions in bed, two or three 
times a day. 

Active motions are started or attempted about 
the tenth week, preferably with the leg submerged 
in a tub of water. No actual weight-bearing is 
allowed until the lateral ligaments have tightened, 
and a caliper may be applied to assist weight- 
bearing, depending wholly upon the sensitiveness 
and pain on use. 

Case I. F. O. K. Age 31 years. In 1909, 
patient had an acute neisserian infection in the 
left knee. The opening of the joint resulted in 




Fig. 6, Case I, F. O'K. Twelve 
years after mobilization, showing 
weight-bearing, January, 1923. 

an ankylosis. The knee was in good position, but 
there was no motion between the tibia and the 
femur. The patella was ankylosed to the femur. 
Manipulations did not result in a gain in motion. 
Arthroplasty was advised. 

December 14, 1910, arthroplasty on left knee 
according to the technique as described. 

December 23, 1910, out of bed. Daily dress- 
ings. 

January 5, 1911, cast removed. Posterior shell 
applied. 

January 7, 1911, small amount of weight-bear- 
ing. Crutches. 



January 19, 1911, patient discharged from hos- 
pital. In a leather leglet with limited motion. 





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Fig. 7, Case I, F. O'K. 95° flexion. 
Twelve years after arthroplasty, 
January, 1923. 

To continue stretching and daily hot fomenta- 
tions. 

January 3, 1923, now twelve years since arthro- 
plasty. No pain and has had no trouble. "No 
bother at all and can do everything. Sometimes 
has to stop and think which is the operated knee." 
Has gained forty to fifty pounds. Leg straight. 
Good power in quadriceps. Complete extension 




Fig. 8, Case I, F. O'K. Antero-posterior roentgeno- 
gram twelve years after arthroplasty, January, 1923. 

and 95° motion in flexion possible. Absolutely 
no lateral mobility. (Figs. 6, 7, 8.) 

The Hip Joint. 
In the hip joint, the method as originally 



planned by the late Dr. John B. Murphy is sub- 
stantially the same as that being used today, with 
the exception that a free fascia transplant is used 
and that the transplant is placed around the head 
and neck of the femur, instead of oyer the ace- 
tabulum. Great care is taken to save the old 
capsule and resuture it over and above the 
head of the femur. The technique is as follows : 

Operative Technique. 

The patient is given a very careful two-day 
preparation of the hip from the rib-line to below 
the knee. A skin incision is made beginning at 
the anterior superior spine and running in a hori- 
zontal plane to about two inches below the level of 
the trochanter, at which point it curves over the 
femur three to four inches below the trochanter 
in a U-shaped fashion. This flap, with consider- 
able fatty tissue, is elevated, raised to its base line 
and retracted. 

A similar incision is made through the fascia 
external to the sartorius and sweeps around 
about three inches below the trochanter, at which 
point it reaches the base of the femur. The 
periosteum is separated downward one-half inch 
and then upward to the base of the trochanter. 

With a two-inch osteotome the entire trochan- 
ter is removed and elevated, taking with it all the 
muscle attachments. 

An incision is then made through the capsule 
beginning on the ilium and passing parallel to 
and in the center of the femoral neck to the base 
of the detached trochanter. At the attachment of 
the capsule to the femoral neck it is cut off on 
both sides for a distance of one and one-half 
inches and retracted. A blunt dissector then frees 
the capsule from the neck as much as possible. 

A study of the junction between the head and 
the ilium is made, and then with a curved chisel, 
covering a small space at a time, the femur is 
separated from the acetabulum. Care should be 
taken to follow the outline of the acetabulum, as 
this is always hard, while the head is usually atro- 
phied. 

Finally the head is freed and dislocated. With 
the Murphy male and female rasp the acetabulum 
is thoroughly reamed out and the head is thor- 
oughly rounded. Great care should be taken to 
remove all spicules of bone. 

A piece of free fascia lata from the outer side 
of the opposite leg is removed and sewed around 
the neck of the femur by interrupted sutures. 
Then a purse string is tied about it tightly. 

The head is reduced. The old capsule is re- 
turned and sewed together and to the old attach- 
ments as nearly as possible. I feel that this very 
materially adds to stability and ensures against 
dislocation or a wabbly, unstable joint. 

The trochanter is then pulled down to its old 
position and held by resuture of the periosteum 
with fascia originally elevated. The skin is closed 
and the leg placed in plaster from the nipple line 
to the toe, with the leg in 10° abduction, complete 



extension, and a little pressure over the tro- 
chanter. 

The cast remains on two and one-half weeks 
and is then removed and traction applied. Passive 
motions are started at the third week and should 
always be within the limits of pain. The patient 
is encouraged to voluntarily contract the thigh 
muscles and thereby get voluntary control early. 

The patient may walk with crutches in six 
weeks and bear a little weight in about eight 
weeks. Convalescence as regards motion varies 
with the type of individual, but all motion should 
be within the pain limits. 

Case I. O. P. Age 24 years. Patient had an 
ankylosis of three years' duration involving both 




Fig. 9, Case I, O. P. Voluntary- 
motion in right hip two and a half 
years after arthroplasty. (Patient has 
about twice this motion, but is handi- 
capped in further flexion by double 
ankylosis of the knee.) 

hips and knees, due to an infectious process, prob- 
ably neisserian in origin. 

April 12, 1920. Arthroplasty of right hip by 
Dr. Andrew R. MacAusland, using the technique 
as outlined. It was then about three years since 
the original infection. The operation was fol- 
lowed by some shock. Perfect healing of the 
wound. Cast applied. 

May 17, 1920. Cast removed and passive 
movements encouraged. 

June 5, 1920. Out of bed with crutches. 

June 10, 1920. Walking with crutches. 

June 12, 1920. Discharged from hospital. 

January 13, 1923. No pain. Motion in flexion 
40°. Motion in adduction and abduction in arc 
of 15° to 20°. (Fig. 9.) 

Case II. O. P. Age 24 years. The previous 
history of this case was reported under Case I. 
Both hips were ankylosed. 



November 2, 1920. Seven months after the 
operation on the right hip, Dr. Andrew R. Mac- 
Ausland did an arthroplasty of the left hip, using 
the regular technique. 

November 29, 1920. Cast removed. Wound 
healed by first intention. 

December 6, 1920. Passive motions started. 

December 17, 1920. Patient up in wheel-chair. 

Some sensitiveness. Omit motion for one week. 

December 26, 1920. Passive motion renewed. 

January 4, 1921. Walking with crutches. 

January 22, 1921. Discharged from hospital. 

January 12, 1923. No pain. Motion in flexion 




Fig. 10, Case II, O. P. Voluntary 
motion in left hip two years after 
arthroplasty. (Patient has about twice 
this motion, but is handicapped in 
further flexion by double ankylosis of 
the knee.) 

40°. Good abduction and adduction. Excellent 
functional result. (Fig. 10.) 

In conclusion, I consider that mobilization of 
the joints in its present stage has been developed 
to a point where excellent results may be obtained 
as a routine in elbow- joint ankylosis ; that arthro- 
plasty is indicated always in double ankylosis of 
the hip, in double ankylosis of the knee or in any 
combination of these, and in ankylosis of the jaw ; 
that ankylosis of the shoulder and ankle joints, if 
in proper position, allows good function, and 
should not be disturbed by any mobilization meth- 
ods. In ankylosis of a single hip-joint or a single 
knee-joint, mobilizing methods should be advised 
with caution and judgment, and should be at- 
tempted only by highly trained technical operators 
who have had considerable experience in mobil- 
izing- methods. 



BROOKLYN EAGLE PRESS 



[Reprinted from the Boston Medical and Surgical Journal, Vol. 190, No. 7, pp. 242-244, Feb. 14, 1924.1 



Intrinsic Splint Traction 



BY J. WARREN WHITE, M.D., BOSTON 



The purpose of this paper is to report a sim- 
ple type of intrinsic traction, which, in my ex- 
perience, has proved of value, and which has 
not been employed, to my knowledge, in the 
form described below. Although a casual search 
of the literature has revealed no type of appar- 
atus embodying its three main principles, it un- 
doubtedly has been used by others. These prin- 
ciples may be briefly stated as follows: .b'irst, 
facility in maintaining a desired amount of trac- 
tion; second, comparatively accurate mensura- 
tion of force employed; and third, ease of ap- 
plication, adjustment and transportation. 

This method of producing extension was the 
result of working with the early iee-tong type 
of skelatile traction, where the necessity exist- 
ed of maintaining a continuous pull for consid- 
erable periods of time. The mechanics of the 
ice tong in the hands of the iceman applies to 
its use on the femoral condyles; that is, as long 
as force is maintained in lifting the cake of 
ice or exerting traction on the skeleton, the 
tong will stay in place. If this force is not 
continued in either case, there is a probability 
of slipping and displacement of the instrument. 
The necessity of a more or less fool-proof and 
stable apparatus was therefore apparent. With 
the adjustable tongs being made now, the need 
of continuous traction is not so imperative. 

As its name indicates, the traction is pro- 
duced and applied within the limits of the 
splint. A Thomas leg splint, or some such modi- 
fication as would be necessary in employing it 
with an upper extremity, is the basis of the 
apparatus. This splint should be sufficiently 
long to allow for at least two feet between its 
distal tip and the distal end of the arrangement 



that is fixed to the extremity, whether is be tong, 
if skelatile traction is used, or ' ' adhesive spread- 
er" or its equivalent, if "skin traction" is uti- 
lized. The advantage of this type of traction 
over the weight-and-pulley arrangement will be 
taken up later on in this paper and I will now 
describe the mechanical details upon which it 
depends. 

The pull is exerted and maintained by three 
elements arranged in series, one end of which 
applied to the distal extremity of the splint and 
the other end to the distal extremity of the ar- 
rangement fixed to the point at which traction 
is desired. The proximal element in this series 
is a bunch of rubber bands of thickness and 
number suitable to the space available and to 
the amount of traction deemed necessary. To 
these india-rubber bands is fastened a spring 
balance of about twenty-five pounds capacity, 
of the type used for weighing infants. A small, 
nicely nickeled spring balance, as above, can 
be obtained at most surgical supply houses for 
about a dollar, which will be satisfactory for 
this purpose. I have found that they retain 
their accuracy, although they do stretch out to 
some extent, even after being used on a con- 
stant traction varying from seventeen to seven 
or eight pounds for six weeks or more. To the 
other end of this scale is hooked a metal chain 
of the type now used in heavy windows instead 
of window cord. This chain is passed about 
the distal end of the splint and hooked back 
on the scale through a link that will give the 
traction desired, which is read directly on this 
scale. It has been found that the combination 
of the india-rubber bands and the balance makes 
it possible by its elasticity to maintain a given 



traction for an indefinite period with little need 
for adjustment. Rarely has more than twenty 
pounds traction been found necessary to effect 
correction of overriding in fractured femurs, 
and in recent cases I have never had to use more 
than twenty-five. It might be stated here that 
I have found it better to employ many small 
rubber bands than a few of the larger type, as 
they can be handled more easily and it makes 
little difference if two or three should snap. 

The usual form of intrinsic traction common- 
ly described depends for its action on the prin- 
ciple of the Spanish windlass. This has been 
found to be impracticable except in emergen- 
cies, as there is no way of measuring the amount 
of traction applied or maintaining it at a con- 
stant amount. The relative lack of elasticity 
results in either too much or too little traction, 
producing discomfort and pressure sores in the 
former event and no correction in the latter. 
Any slight variation in the distance from the 
point at which traction is applied on the limb 
and the distal extremity of the splint produces 
a great amount of variation in the force exert- 
ed. The stretching of the rope used in the 



windlass also tends to reduce the amount of 
traction in a short time. 

While this apparatus is used most commonly 
on the lower extremity, it can be almost equally 
well employed with a Jones humerus exten- 
sion splint, the Thomas traction arm splint, or 
even in forearm conditions where a Jones splint 
is used and traction desired. While I stated 
above, two feet is wanted where possible, this 
type of traction may be employed within a 
space of ten inches. 

The leg is supported by the usual transverse 
slings attached to the bars of the splint, which 
itself is supported by some form of adjustable 
upright fixed to the foot of the bed or the Brad- 
ford frame, the latter being most convenient in 
handling these cases, which are necessarily bed- 
ridden, while active traction is being employed. 
If the pressure on the ischial tuberosity and 
pubic ramus becomes uncomfortable, the foot of 
the bed may be elevated, allowing the body to 
pull slightly away from the ring. This, natural- 
ly, increases the amount of traction, which is 
immediately noted on the scale, and the neces- 
sary adjustment can be made. The apparatus 





Window chain. 



Twenty-five-pound spring balance showing graduations read directly 
to show amount of traction applied. 



Bunch of rubber bands to increase elasticity. 



Adhesive "spreader." 



Fig. I. — Showing arrangement of the three elements producing the traction, one end attached to an adhesive "spreader" and the 
other to the distal extremity of a Thomas splint. 

2 



// 



is so stable that no risk is run in moving the 
patient on the frame to another bed, or to a 
truck for ease in transportation outdoors or to 
the x-ray department. The fact that the entire 
apparatus is a unit on the frame and cannot 
be easily disarranged is an argument in its favor 
when one compares it with the cumbersomeness 
of the weight-and-pulley mechanism usually 
necessitating the Balkan frame. The ease in 
obtaining x-rays is of great value in effecting 
and maintaining position with a minimum of 
traction. This in itself predisposes good re- 
sults. Excessive traction that tends to separate 
the fragments must be avoided as it is undoubt- 
edly a cause of delayed union. Sufficient force 
to maintain position is all that is desired. 

The efficiency of this arrangement will ap- 
peal to the man who has had to care for frac- 
tured femurs on a busy ward surgical service, 
where it is difficult to give these cases the neces- 
sary personal attention that will insure the 
proper functioning of the extension apparatus. 
The usual way of treating the average frac- 
tured femoral shaft at present is by extrinsic 
weight-and-pulley traction with suspension of 
the extremity. This is, of course, more efficient 
than the old Buck's extension, even if a Volk- 



man's sliding rest is used to minimize the fric- 
tion of the lower leg on the bed. Not infre- 
quently the morning hospital visit finds cases, 
supposed to be "on traction," without a pound's 
pull being exerted. A few of the commoner 
reasons for this are : sliding the patient in bed, 
bringing the "spreader" against the upright 
holding the pulley, the rope being off the pul- 
ley and wedged down beside it, the pulley itself 
being jammed for some reason or other, the 
weights resting either on the floor or on a cross- 
bar at the foot of the bed, slipping a knot in 
the rope against the pulley, and so on. 

It is not only for reducing and maintaining 
fractures in apposition that this form of trac- 
tion is useful, but it is for any condition where 
traction is indicated, such as in the correction 
of flexion deformities, immobilization in acute 
or chronic arthritis or septic joints, including 
cervical caries or arthritis, where the Bradford 
frame is used as a splint, and in arthroplasties, 
particularly of the hip and knee. The conven- 
ience and efficiency of this type of apparatus 
suggests its use where the more cumbersome 
and complicated weight-and-pulley traction 
would not be considered. 
240 Newbury Street. 




Cord regulating passive motion under control of patient. 



Upright holding splint in anti-aircraft position, resting on foot 
of bed. 



Traction without using chain because of lack of space, amount 
used obtained by employing proper number of rubber bands. 



Fie. II. — Intrinsic splint traction being used in postoperative care of an arthroplasty on a knee. Ten pounds traction is usea 
and early passive motions under control of patient within the limits of pain urged. 

8 



PRESS OF JAMAICA FEINTING COMPANY, BOSTON, MASS., C. B. A. 



o 



REPRINTED FROM 

ANNALS OF SURGERY 

227 South Sixth Street, Philadelphia, Penna. 
December, 1924. 



ASTRAGALECTOMY (THE WHITMAN OPERATION) IN 
PARALYTIC DEFORMITIES OF THE FOOT 

By W. Russell MacAusland, M.D. 

SURGEOX-IN-CHIEF, ORTHOPCEDIC DEPARTMENT, CARNEY HOSPITAL 

AND 

Andrew R. MacAusland, M.D. 

of Boston, Mass. 

In 1916, one of the writers :i read before the Orthopaedic Section of the 
American Medical Association a paper on " Astragalectomy in Infantile 





X. 








Fig. 1. — Astragalectomy — the Whitman operation. Line of incision. 

Paralysis," which included a review of the literature of the subject up to that 
time, and covered a series of one hundred and thirty-five cases. In 1920, 
J. W. Sever 18 published an article in the Journal of the American Medical 
Association, reporting two hundred and seventeen cases of astragalectomy 
done at the Boston Children's Hospital, by eight surgeons. The results 
recorded by Sever are so diametrically opposite to those which were reported 
in the above paper that, in justice to the classical operation described by 

861 



MacAUSLAND AND MacAUSLAND 

Whitman, 22 we believe it necessary to make a further report of a series of 
two hundred and forty-seven of our own cases. 

The Importance of Muscle Balance in the Foot.— The normal foot is 
balanced by muscles which work in perfect coordination, assisted by ligaments 
which check the extremes of motion. When paralysis involves the foot, the 
resultant damage varies from a slight, almost unrecognizable lack of muscle 




. . J 

Fig. 2. — Tendon of peroneus longus exposed; tendon of peroneus brevis being exposed. 

balance or weakness of a single group, to a complete paralysis of all the 
muscles. Lack of muscle balance causes two serious conditions, instability and 
deformity. The instability, which is greatly increased by the presence of 
paralysis elsewhere, may impair function out of all proportion to the extent 
of the paralysis. Deformity develops eventually in practically all cases from 
unopposed muscle pull. The recognition of this fact and the prevention of 
deformity are most important, since no reconstructive surgery can be done 
until all deformity has been corrected. 

The Relation of Shortening {and Atrophy) to the Extent of Paralysis. — 
Instability, particularly with the additional handicap of deformity, is the 
major factor in determining the amount of shortening. The authors observed 
long ago that many severe and extensive paralyses developed only one or two 

862 



ASTRAGALECTOMY 

inches of shortening, whereas many cases with a single paralyzed group of 
muscles had as much as two to four inches. Analysis showed that patients 
using the leg well in walking developed less shortening than those using the 
leg poorly. Further, it was apparent that insecurity or instability of the foot 
caused the patients in the latter group to hop quickly over the weak leg, using 
it as little as possible. This explains perfectly why calcaneovalgus is asso- 








Fig. 3. — Peroneal tendons sutured and divided. 

ciated with more shortening than one would expect from a single group 
paralysis ; and, conversely, why almost flail legs vigorously used, show less 
shortening than one would expect. It becomes unnecessary to fall back on the 
term " trophic " to explain shortening. 

Early " stabilizing " operations are amply justified to avoid shortening. 

The Object of Astragalectomy. — The object of astragalectomy is to make 
a new ankle-joint (an arthroplasty) which, with such muscle as is present, 
will be stable and well balanced. When properly done, an astragalectomy 
shifts the weight-bearing line to the front by the forward displacement of 
the tibia and the fibula, thereby obtaining a so-called " rocking-horse foot," 
with the weight-bearing near the middle — the point of advantage — rather than 
on the " backstep of the rocking horse " as is clinically seen in a case of 
calcaneovalgus. The fulcrum is increased by the lengthening of the posterior 
arm or the distance between the weight-bearing line of the tibia and fibula 

863 



MacAUSLAND AND MacAUSLAND 

and the back of the heel. This change in weight-bearing is particularly 
efficient when the peronei are transplanted into the Achilles tendon, in which 
position they not only tend to prevent recurrence of calcaneous but in most 
cases may even assist in plantar flexion. 

Astragalectomy not for Ankylosis but for Mobility (Arthroplasty). — 
There seems to be a widespread impression that the operation results in anky- 







Fig. 4. — External lateral ligament divided; tibio-astragaloid ligament divided; interosseus and external 

talocalcaneal ligaments being divided. 

losis, but ankylosis is neither sought nor expected, and if it does occur should 
be regarded as an unfortunate result. Astragalectomy has a distinct advan- 
tage over arthrodesis, in that it not only stabilises but also preserves motion. 

Indications and Contra-indications. — Astragalectomy should never be done 
in the presence of any structural deformity. This, if present, should be 
corrected by manipulative methods and the foot held in overcorrection for 
several months (walking being allowed) before astragalectomy. This neces- 
sary principle may have been overlooked in some of the many failures reported 
in the series from the Boston Children's Hospital. 

Astragalectomy is indicated in calcaneus deformities, especially in valgus, 
for which it was originally devised by Whitman. 22 In calcaneovarus, it is 
important first to eliminate all varus deformity by repeated stretchings and by 

864 



ASTRAGALECTOMY 




retention of the foot in 
overcorrection. After 
months of overcorrection, 
astragalectomy may be 
done with safety. 

In danglc-foot astraga- 
lectomy results in stability, 
the weight being trans- 
ferred to the centre of the 
foot, the arch elongated, 
and the os calcis made 
more horizontal. In cases 
in which only the plantar 
flexors remain, great care 
must be taken to prevent 
the deformity of equinis. 

In equinis deformities 
(with no power in the 

, • \ , Fig. 5. — Dislocation of astragalus by strong inversion of foot. 

anterior group ) aStraga- Note heavy dissector under neck by which astragalus is pried loose 

lectomy is useful in in- headfirst - 

creasing stability, but great care must be taken to prevent a recurrent deform- 
ity. In severe equinovarus, after repeated stretching, the removal of the 

astragalus is frequently 
the coup-de-gras needed 
to complete and maintain 
a serviceable foot without 
deformity. 

Astragalectomy is very 
valuable in severe claw- 
foot. The great relaxa- 
tion of the soft tissues 
occasioned by the removal 
of the astragalus gives the 
opportunity to save many 
feet that otherwise would 
be amputated. Slight or 
moderate varus and equi- 
novarus may be treated 
by other methods. 

Formerly we have in- 
cluded a few cases of 
equinovalgus in our list 
of astragalectomies, but the recent addition of the " loop " operation, also 
devised by Whitman, is replacing astragalectomy or astragalo-scaphoid arthro- 

865 




Fig. 6. — Widening tibia-fibular articulation by removal of thin slice 
of cartilage from internal malleolus. 



MacAUSLAND AND MacAUSLAND 




Fig. 7. — Widening the tibia-fibula articulation by removal of 
thin slice of cartilage from one or both; the internal lateral ligament 
has been dissected up to sharpen the malleolus. 



desis in paralysis of the 
anterior tibial. 

A g e. — Any operative 
interference should be 
withheld until two years 
have elapsed since the 
original paralysis. It is 
neither necessary nor ad- 
visable to do an astraga- 
lectomy before this period. 
Also, we do not advise an 
astragalectomy before the 
age of six years, and it is 
better to wait until the 
child is eight years old. 
The ages between eight 
and sixteen years have 
been found the best, for 
in this period motion is 
easily preserved. 

Operative Technic. — Asepsis should be guarded carefully and all manipu- 
lations should be gentle. A tourniquet is applied after the Esmarch bandage. 

A curved or L-shaped 
incision is made around 
the external malleolus ex- 
tending forward over the 
head of the astragalus. 
(Fig. 1.) The upper flap 
is then dissected upward, 
exposing the tendons of 
the peroneus longus and 
brevis, which are dissected 
free and severed at the fib- 
ular tip. The ends are 
sutured with No. 2 catgut 
and retracted. (Figs. 2 
and 3.) An incision is 
then made through the 
external ligaments around 
the astragalus, special care 

Up- p. f a k- pn n h nn f fVip VipoH Fig - 8 ' — The new articulation for internal malleolus. Note 

ucing Lctis.ciid.uuuL UlC UCdU removal of inner one-fourth to one-sixth from inner side of scaphoid, 
of the astragalus (Fif tlmS forming P° cliet for sharpened internal_malleolus. 

4.) The foot is then strongly inverted. By means of a blunt dissector placed 
under the neck of the astragalus the bone is pried out of position, head first, 

SfiG 




ASTRAGALECTOMY 



and removed— a veritable coup-de-main when well done, taking less than thirty 
seconds. (Fig. 5.) The ease with which the foot may be displaced backward 
will be appreciated at once, but in order to ensure a good, stable joint a certain 
amount of careful modelling must be done. 

The internal lateral ligament is dissected upward from the internal mal- 
leolus, more in cases of equinovarus than in other cases. If necessary, a strip 
of cartilage is removed 
from both tips to allow 
spanning of the scaphoid 
and cuboid. (Figs. 6 and 
7.) A thin slice of bone 
is then excised from the 
sides of the scaphoid and 
cuboid to form pockets 
for the malleoli. (Figs. 8 
and 9.) The foot is dis- 
placed backward and held 
carefully in this position 
to ensure the proper rela- 
tions in the new joint. 
This backward displace- 
ment of the foot which 
checks lateral movements 
by actual bony contact be- 
tween the scaphoid and 
the tibia, is the essential 

feature Of the Whitman p IGi p.— Dissection of ligaments up to make pocket for fibula by 
, • a 1 , the cuboid. 

operation. A moderate 

equinovalgus ensures stability while holding. (Figs. 10, 11 and 12.) The 
peronei are disposed of by (a) suture to the Achilles tendon, by (b) tendon 
fixation to the fibula, or by (c) resuture to the tendons of the peronei, as 
indicated in the given case. (Figs. 13, 14, and 15.) The skin is closed 
with catgut, and plaster is applied from the toes to the mid-thigh with 
the knee flexed and the foot in slight equinovalgus. (Fig. 16.) The leg 
is kept elevated for a period of ten days, after which crutches may be used. 
The first change of plaster case takes place in three or four weeks, at which 
time the equinus is corrected to a right angle in cases where the quadriceps 
is present, or is left in 5 to 8° equinus in cases in which the quadriceps is 
paralyzed. The mechanical value of this must be apparent. Valgus should 
persist to a slight degree throughout the treatment. 

A leather shoe is then put over the plaster and the child is allowed to 
walk, changing the plaster as necessary during the next five or six months. 
After its removal, a shoe with a lift on the outer side of the sole is used 
to maintain valgus. A one-half or three-quarters inch cork lift worn 

867 




MacAUSLAND AND MacAUSLAND 

under the heel throughout life will compensate for the shortening of the leg 
and improve the gait. Circulation improves rapidly with the return of active 
use, loss of growth ceases, and the paralyzed leg begins to grow at a rate 
equal to that of the well side. 

After the removal of the plaster, it is sometimes advisable for older 
patients to wear a limited motion ankle brace, either in the form of an ortho- 







"tSr 



Fig. io. — Fibula and tibia being inserted into pocket. 

paedic shoe or an inner or outer upright to protect the foot from strain during 
the early months of weight-bearing. 

Steps in Technic. — i. Correct all existing deformities before open 
operation. 

2. Astragalectomy may be done with or without tendon transplantation, 
tendon fixation of the peroneals or transplantation through the Achilles and 
resuture, with strong displacement of the foot backward. 

3. Proper after-care. This should be followed by the operator and not 
by untrained assistants. 

4. Prevention of Complications. Recurrent deformity is due to improper 
post-operative care. 

Lack of posterior displacement is due to careless or improper operative 
technic, such as failure to remove head of astragalus. (See reproductions 
of X-rays accompanying Sever's 18 paper.) 

868 



ASTRAGALECTOMY 

We recently examined two hundred forty-seven cases operated from 
two to ten years ago. The majority of the cases were calcaneovalgus deformi- 
ties, but varus, equinovarus, equinovalgus, and dangle-foot types were also 
represented. The age of the patients varied from three to twenty years, with 
an average age of eight to ten years. 

In all cases of calcaneovalgus the peroneals were transplanted into the 
Achilles, with resulting increased function. In twelve cases, the peronei were 




2pa"icl, no - 




\ 



Fig. ii. — The external malleolus rests in a similar socket over calcaneo-cuboid joint. Note. — I, backward 
displacement of foot. 2, fibula carried well forward. 

fixed to the fibula with satisfactory results. The foot was kept in plaster for 
an average of five months. 

Out of the two hundred forty-seven cases, post-operative deformity 
developed in twelve, and of these varus developed in seven. In the later group, 
one patient refused after-treatment following astragalectomy ; one insisted 
that the family physician change the cast ; and the remaining five developed 
deformities from improper after-care in our hands. These, however, were 
corrected in every case before the patient was finally discharged. 

One case of equinovarus deformity recurred. The patient did not return 
to the clinic for after-care. 

There was one case of sloughing of the toe from swelling which developed 
because the patient was taken home and no attempt was made to keep the 
leg elevated ; the end result was good. 

869 



MacAUSLAND AND MacAUSLAND 

The satisfactory results we have obtained lead us to recommend the 
Whitman operation in most cases in which stability with motion is desired. 






ILLUSTRATIVE CASE ABSTRACTS 

Case I. — F. H. Age thirteen. Calcaneovalgus deformity, 
the left leg. Duration: Nine years. Cause: Infantile paralysis, 
this patient had a " fever " resulting in paralysis of the left leg. 

Physical Examination. — The left foot was held in calcaneovalgus deformity. 



Complaint: Limp of 
At four years of age, 



There 




Fig. 12a. — Normal relation of tarsal bones. 

was power in the peronei and the outer dorsal flexors, but there was no power in the 
posterior or inner groups. There was one and three-fourths inches shortening, mostly 
in the lower leg. The quadriceps was present, although weak. 

Treatment : October 14, 1919. — An astragalectomy was performed according to the 
usual technic. Plaster was applied with the foot in about 5 plantar flexion. The 
case above the knee was removed at the end of three weeks. New cases were applied 
on November 29, 1919 and February 24, 1920. About the fifth week, felt was put under 
the heel and the patient was allowed to walk on the plaster case. 

March 20, 1920. — The cast was removed and a flannel bandage applied. 

March 31, 1920. — The foot was in excellent position and the patient was advised 
to wear a three-eighths inch lift under the heel inside the shoe. 

October 18, 1920. — The position of the foot was excellent, and there was good 
motion. A one and three-fourths inch lift was worn under the heel, a one and one-half 
inch lift under the sole, and a one and one-fourth inch lift at the toe. Of this amount, 
one-half inch was put inside the shoe at the heel and one-fourth inch at the sole. 

April 16, 1923. — The foot was in excellent condition. Result: Good function. 

Case II. — J. Hart. Age ten. Calcaneovalgus deformity. Complaint: Lameness. 
Duration: Since seven months old. Cause: Infantile paralysis. The onset was sudden. 

870 



ASTRAGALECTOMY 

When seven months old the patient had infantile paralysis, and was in bed three weeks. 
At first both legs were affected, but later only the feet were in bad condition. 

Physical Examination. — Calcaneovalgus of the left foot. Outer hamstrings absent; 
left thigh and gluteal muscles about one-half normal. No power in the calf muscles or 
in the extensors of the toes. 

Treatment: May 27, 1919. — An astragalectomy was performed according to the 




Fig. 12b. — Relations following the properly done astragalectomy. 

usual technic and a plaster case applied with the foot displaced backward, and in slight 
valgus and equinus. 

June 24, 1919. — The case above the knee was removed. 

July 22, 1919. — A light plaster case was applied from the toe to the knee, and the 
sole reinforced with the foot at a right angle. 

September 2, 1919. — A new case was applied. This was removed on October 
28, 1919. 

January 6, 1920. — The left leg was one and one-half inches shorter than the right. 
A one and one-fourth inch lift was worn under the heel, one-half inch of which was on 
the inside of the shoe. A one-inch lift with one-fourth inch inside the shoe was worn 
on the sole. 

Result: March 1, 192 1. — Examination showed an excellent result. 

Case III. — B. P. Age seven. Calcaneovalgus deformity. Complaint: Slight limp 
and turning of left ankle. Duration: Three to four years. Cause: Infantile paralysis. 
When the patient began to walk she had difficulty with balance. 

Physical Examination. — Walked with marked pronated feet and heel was wabbly. 
Good dorsiflexors. Excellent peronei. No inner or posterior group. Astragalectomy 
with transplanting of peronei into the Achilles advised. 

Treatment: May 1, 1923. — Astragalectomy was performed without transferring the 
peroneal tendons. Plaster applied in toe-drop, to be changed in three weeks. 

May 31, 1923.-Ca.se was removed and a new one applied. There was a slight 
serous discharge. 

871 



MacAUSLAND AND MacAUSLAND 

June 21, 1923. — There was still some sloughing. The patient began to walk on the 
case and bend the knee. 

August 21, 1923. — The case had been removed when the scab fell off, and was 
replaced by a flannel bandage. The foot was at a right angle. There was io° to 
15 motion. 

November 13, 1923. — Foot at a right angle. Massage advised to increase circulation. 
A one-quarter inch wedge put under heel to compensate for shortening. 

December 11, 1923. — Walks with eversion of left leg, but with good foot balance. 
About 25 ° motion. No pain. Excellent displacement. (Figs. 17, 18, and 19.) Result: Good. 

Case IV.- — M. C, Age six. Calcaneovalgus deformity. Complaint: Foot turned 







Fig. 13. — -Disposition of the tendons of the peronei into the tendo-Achillis. 

out. Duration: Three years. Cause: At three years of age patient had infantile 
paralysis which left her unable to walk. She gradually recovered, but the left foot did 
not respond to treatment and its condition grew worse. 

Physical Examination. — The child walked with marked valgus of the left foot. The 
anterior tibial and peronei were present, although the former was weak. There was no 
Achilles or posterior tibialis. The left leg was one-half inch shorter than the right. 

Treatment : May 24, 1913. — An astragalectomy and transplantation of the peroneals 
into the tendo-Achillis was performed according to the usual technic. 

Result: December 22, 1914.- — The functional result was good. The left foot was in 
good position. 

Case V. — M. O'B. Age eight years. Calcaneovalgus deformity. Complaint: 
Deformity of the right foot. Duration: Six years. Cause: Infantile paralysis. 

P. I. — July, 1913. The patient entered the out-patient department with history of 
having had anterior poliomyelitis six years before. When first seen she complained of a 
limp and deformity of the right foot. 

872 



ASTRAGALECTOMY 

Physical Examination. — Negative except for the deformity of the right foot. The 
examination showed the absence of the inner and posterior groups of muscles. (Fig. 24.) 

The patient was advised to enter the hospital for operation. A regular astragalec- 
tomy was performed, including the transplantation of the peroneal tendons into the 
Achilles and os calcis. 

The convalescence was managed in the routine manner, and was uneventful. 

Restdt. — The end-result was excellent. 

Case VI. — E. D. Age eight years. Calcaneovalgus deformity. Complaint: 
Deformity of the left foot. Duration: Four years. Cause: Infantile paralysis. 










FlG. 14. — Disposition of tendons of peronei into the Achilles tendon and resuture and tendon fixation 

(Galli operation). 

Physical Examination. — There were no contractures. The gastrocnemius and plan- 
tar flexors were absent. The quadriceps, anterior tibial and peroneal muscles were in 
good condition. There was shortening of one and one-half inches. The left foot was in 
calcaneovalgus deformity. 

Treatment. — In December, 1914, an astragalectomy and transplantation of the pero- 
neal tendons into the tendo-Achillis were done. 

Result: January 22, 1924. — The foot was at a right angle and in excellent posterior 
displacement and good alignment. There was 10° motion in the mid-tarsal joint. The 
patient was wearing a lift under the heel and sole of shoe. 

Case VII. — C. V. A. Calcaneovalgus deformity. This patient had a calcaneo- 
valgus deformity on the left foot, due to infantile paralysis. A regular astragalectomy 
was done. 

873 



MacAUSLAND AND MacAUSLAND 

Result. — The result was good, with posterior displacement of foot in good alignment. 

Case VIII.— K. M. Age four. Valgus deformity. Complaint: Left foot deformed. 
Duration: One year. 

Cause. — Infantile paralysis. The onset was sudden; the patient on getting out of 
bed was unable to walk. 

Physical Examination. — The child walked with a marked valgus of the left foot. 
The peronei were present. There was no anterior tibial. The tendo-Achillis was slightly 





Fig. 15. — Disposition of tendons of peronei into Achilles tendon, and resuture of ends. 

contracted. Abduction of the foot was not possible. The entire left leg was mark- 
edly atrophied. 

Treatment: April 19, 1913. — A regular astragalectomy with transplantation of the 
peronei into the os calcis was done. 

Result: June 4, 1915. — An excellent functional result was obtained. She walked 
well; motion from 85° to almost 180 was possible. 

Case IX. — J. H. Age thirteen. Valgus deformity. Complaint: Walked with left 
limp. Duration: About twelve years. Cause: Infantile paralysis at the age of twenty- 
two months. 

Physical Examination. — Left foot in marked valgus. Slight power in the extensors 
and Achilles tendon. No power in the tibialis anticus. (Fig. 20.) Glutei very weak. 

Treatment : June 24, 1919. — Astragalectomy according to the regular technic. 

August 5, 1919. — New case applied with the foot at a right angle. Patient began 
to bear weight. 

November 18, 1919. — Case removed. 

874 



ASTRAGALECTOMY 



December 19, 1919. — Foot in fine condition. The patient was wearing a shoe with a 
one and one-half inch lift under the heel. 

March 20, 1920. — The patient stood with the foot in slight valgus. The leg was two 
and one-half inches shorter than the right. A one and one-fourth inch bevelled lift was 
worn under the sole of the shoe, of which one-fourth was worn inside the shoe. 

May 25, 1920. — The patient walked very well with shoe. Exercises begun. 

Result: June 21, 1921. — An excellent result. The foot was at right angles, and there 
was good displacement and good control. There was flexion of 25 . (Figs. 21 and 22.) 



B 





'< 










Fig. 16. — In plaster, following operation. 

Case X. — C. H. Age nine. Varus deformity. Complaint: Lameness. Duration: 
Six years. Cause: Infantile paralysis. 

At three years of age this child had a fever which was followed by paralysis of the 
right foot that resulted finally in a varus deformity. 

The foot was manipulated and the deformity corrected into a slight valgus. 

On account of the general muscular weakness of the foot, as well as the absence 
of the peronei and the anterior muscle group, as astragalectomy was performed. 

Two years later there was 25° motion in the ankle-joint. The foot was in good 
position and the patient walked splendidly. There was good stability and no pain. 

Case XI. — C. S. Age sixteen. Talipes equinus (extreme). Complaint: Lameness. 
Duration: Thirteen years. Cause: Infantile paralysis. 

875 



MacAUSLAND AND MacAUSLAND 




At three years of age this patient had a " fever " result- 
ing in loss of use of the right leg. Improvement followed, 
but the right foot remained in extreme deformity. 

Physical Examination. — Negative except for the con- 
traction of plantar fascia and the Achilles. The peronei 
were present. The leg was one and three-eighths inches 
shorter than the left leg. The diagnosis was made of 
extreme talipes equinus, due to anterior poliomyelitis. The 
foot was manipulated and the plantar fascia contraction was 
first corrected. 

May ig, 1914. — A regular astragalectomy was done, 
followed by the application of plaster from toe to just 
above the knee. 

June 30, 1914. — A new plaster case was applied from 
the toe to the knee with the foot at a right angle. Several 
changes were made later, and the patient was allowed 
to walk on plaster with a three-eighths wedge under 
the heel. 

July, 1913. — The functional result was good. There 
was good valgus, and the motion at the ankle was good. 

Case XII. — L. M. Age fourteen. Calcaneocavus de- 
Fig. 17. — Case III, B. P.,cal- formity. Complaint: Walks with left heel limp. Duration: 

caneo-valgus deformity. Ante- . , , „ T r ., , . , 

rior view after astragalectomy About twelve years. Cause: Infantile paralysis at the age 

(Whitman). , , 

of twenty months. 

Physical Examination: August 7, 1923. — The left foot was in slight cavus. The leg, 
especially the calf, was atrophied. The iliopsoas, quadriceps and the tibialis anticus were 
strong. The gastrocnemius and the peronei 
had no power. (Fig. 23.) 

Treatment: October 17, 1923. — Astrag- 
alectomy was done together with tendon 
fixation of the flexor longus hallucis to 
prevent plantar flexion deformity of the 
great toe. 

November 27, 1923. — Ninety degrees to 
thirty degrees extension was possible. 

January 22, 1924. — The case was re- 
moved and a flannel bandage applied. Mas- 
sage of the calf was begun. The patient 
began to bear weight and was to begm 
walking as soon as possible, without a lift 
in the shoe. (Fig. 23.) Note posterior 
displacement. 

Discussion of Doctor Sever's Re- 
port of Cases. — Our end-results are 

SO different from those reported in F IG . 18— Case III.B. P., calcaneo-valgus deformity 
t-\ . r- , 1. • ;1 •• Lateral view after astragalectomy. (Whitman.) 

Doctor bever s 18 series, that it is 

interesting to try to explain the factors which account for the differences. 

We believe there are three : 







876 



ASTRAGALECTOMY 




i. Failure to correct the structural deformity before operation. One 
hundred and eighty-eight cases had deformity, but no mention is made of its 
correction before astragalectomy. Sixty-five cases had varus deformity, 
which should always be corrected before operation. 

2. Lack of proper operative technic. — (a) Failure to remove the head of 
the astragalus. X-rays accom- 
panying the report show that the 
head of the astragalus has not 
been removed. This fact is not 
noted in the report. 

(b) Failure to displace the 
foot properly. Sever admits 
failure due to lack of displace- 
ment in thirty-five per cent, of 
the fifty-four cases on which 
there is a note. 

3. There are several factors 
in the operative technic on which 
Doctor Sever did not seem to be 

clear. The operation was Origi- Fig. 19.— Case III.B. P., calcaneo-valgus deformity. Degree 
., , . , 1- ,, , of motion after astragalectomy (Whitman). 

nally designed for the calcaneus 

type of deformity, yet only fifty-two of the two hundred seventeen cases were 
of this type. The operation was also designed for cases involving paralysis of 
the gastrocnemius, but it was used in sixty-nine cases in which the gastroc- 
nemius was active. Sever also appears to have anticipated a stiff ankle, which 
is not the aim of astragalectomy. Sever believed that the equinus position was 

the one sought by the 
operator, but this is true 
only in the absence of a 
quadriceps and even then 
only 5 to 8° toe-drop is 
advisable. In " Table No. 
5 " Sever records one 
hundred eight cases as 
having good " lateral 
movement." The object 
of the operation is to 
establish stability by lim- 
iting the lateral motion. 
Sever and his opera- 
tors have failed in all the above essentials and their end-results might have 
been anticipated. We believe, as does Whitman, that the end-results and 
tabulations reported by Sever are of little value. 

Literature. — Astragalectomy was first reported in the records of the 
Hospital for Ruptured and Crippled Children in 1897. Whitman 22 designed 

877 




Fig. 20. — Case IX, J. H., valgus deformity. Lateral view before 
astragalectomy (Whitman). 



MacAUSLAND AND MacAUSLAND 




Fig. 2i.— Case IX, J. H., 

valgus deformity. Anterior 
view after astragalectomy 
(Whitman). 



it for calcaneus deformities of advanced degree, but its application has been 
broadened extensively and in a series of sixty cases reported more recently 

by Doctor Whitman 23 only sixteen were calcaneus 
deformities. 

Whitman's results certainly corroborate the value 
of this operation. Armitage Whitman, 23 in 1922, 
issued his report on a series of sixty cases, extending 
over a period of five years. Twenty-eight of these 
cases were operated upon by Royal Whitman and 
thirty-two cases by other surgeons. Ninety per cent, 
of the patients were satisfied with the results ; sixty- 
five per cent, discarded braces. The best results were 
secured in calcaneus deformities. The causes of fail- 
ure in their order of frequency were : insufficient 
backward displacement of the foot, varus deformity 
from faulty technic, persistence of the original defor- 
mity, and removal of the support of the head of the 
astragalus from the scaphoid. 

Doctor Whitman bases the success of his opera- 
tion on the proper selection of the cases, a thor- 
ough understanding of the mechanical principles 
on which the operation is based, exact operative technic, and apprecia- 
tion of the deformity before operation, and of the recurrent distortion. 

The Whitman operation has many advo- 
cates. Dane and Townsend 4 have reported 
three successful results, one for calcaneus 
deformity, and two for calcaneovalgus defor- 
mity. Gibney, 6 Taylor 20 and Albee 1 are in 
favor of it. Bradford 2 has found in his 
experience in the Boston Children's Hospital 
that the Whitman operation has given the 
best results. 

Tubby, 21 Lord, 10 Reed, 15 Campbell, 3 
Rogers, 17 Orr, 13 and Gillette and Chatterton, 7 
and Henderson 8 endorse the Whitman oper- 
ation enthusiastically, particularly for talipes 
calcaneus. 

Other surgeons have found astragalec- 
tomy of value in other deformities. Nathan, 12 
and Henderson 8 consider that calcaneovalgus form f t y; 2 Z^£%%£? £t«"asSie£ 
is corrected most efficiently by the Whitman tomy < Whitman ^ 
operation. Gallie, 5 too, recommended it for extreme cases of calcaneovalgus 
and also for dangle- foot ; Roberts 16 has secured many good results in typical 
dangle-f oot. Stern and Cook 19 have reported that out of two hundred fifty 

878 




ASTRAGALECTOMY 



3 
a 



O 



X 



B 

e-t-* 






3 2. 



oq 



o 
3 




879 



MacAUSLAND AND MacAUSLAND 

cases of astragalectomy that they investigated, only twenty relapsed and these 
could be corrected by a secondary operation. They recommend the opera- 
tion particularly for paralytic talipes, talipes calcaneocavus, flail and dangle- 
f eet in children ten to fourteen years of age. Packard u reported eight 
successful cases, six of flail ankles, one of marked calcaneovalgus, one of 
everted foot with toe-drop. 

In discussion of Hoke's paper 9 on the arthrodesis operation, Wallace 
advocated the Whitman operation, particularly for calcaneous, calcaneovalgus, 
and dangle-foot. He has used or observed it in one hundred fifty to two hun- 
dred fifty cases and there has not been a case in which the patient was not 
materially benefited. He does not consider age a barrier to the operation, 
but believes that interference should be made two or three years after the 
original onset. 

The many good functional and cosmetic results obtained from properly 
performed astragalectomy account for its acceptance as the operation of 
preference. It has gradually replaced many other operative procedures that 
have been devised to increase function in paralytic conditions of the foot. 

BIBLIOGRAPHY 

1 Albee: Orthopaedic and Reconstructive Surgery, 1919, p. 776. 
2 Bradford: In Discussion of Whitman's Paper, 1908. 
'Campbell: J. A. M. A., Oct. 11, 1913. 

* Dane and Townsend : Am. J. Orthop. Surg., vol. ii, 1904-5, p. 38. 
5 Gallie: Am. J. Orthop. Surg., Phila., 1916, vol. xiv, p. 18. 

6 Gibney : In Discussion of Whitman's Paper, 1908. 

7 Gillette and Chatterton : Journal-Lancet, Minneap., 1917, vol. xxxvii, p. 691. 

8 Henderson : St. Paul M. J., 1917, vol. xix, p. 365. 
"Hoke: J. Orthop. Surg., vol. iii, p. 494, Oct. 19, 1921. 

10 Lord: J. A. M. A., Oct. 11, 1913, p. 1374. 
11 MacAusland, W. R. : J. A. M. A., vol. lxviii, 1917, p. 239. 
"Nathan: Am. J. Orthop. Surg., 1914-15, vol. xii, p. 444. 
13 Orr : Am. J. Orthop. Surg., Bost., 1916, vol. xiv, p. 336. 
" Packard : Colorado Med., Denver, 1916, vol. xiii, p. 93. 

15 Reed: J. A. M. A., Oct. 11, 1913. 

16 Roberts : N. Y. M. J., 1916, vol. ciii, p. 826. 

17 Rogers : Am. J. Orthop. Surg., Bost., 1916, vol. xiv, p. 381. 

18 Sever : J. A. M. A., vol. lxxv, p. 1200, Oct. 30, 1920. 

19 Stern and Cook: J. Orthop. Surg., vol. iii, pp. 437-444, Sept., 1921. 

20 Taylor: Am. J. Orthop. Surg., Boston, 1916, vol. xiv, p. 394. 

21 Tubby: Clinical Journal, vol. xl, June 19, 1912, p. 164. 

22 Whitman, R. : A Treatise on Orthopaedic Surgery, N. Y., Lea and Febiger, 1919, p. 806. 

23 Whitman, A. : J. Bone and Joint Surg., Bost., 1922, vol. iv, p. 266. 



880 



Reprint from SURGERY, GYNECOLOGY AND OBSTETRICS, June, 1924, pages 739—747 

RECURRENT DISLOCATION OF THE SHOULDER 

With Report of Cases 
By W. RUSSELL MacAUSLAND, M.D., Boston, Massachusetts 

Surgeon-in-Chief, Orthopedic Department, Carney Hospital 

RECURRENT dislocation of the hum- In some cases the lower glenoid margin is 
eral head occurs most frequently in found worn off. In others there may be loose 
early adolescence. It is generally pre- bodies or avulsion of the great tuberosity. In 
ceded by a history of trauma, the original some of the severer cases an actual pulling 
injury having been sufficient to produce a away of the inferior capsular ligament with 
subglenoid or subcoracoid dislocation of the its bone attachment may take place, thus 
head. Men are more prone to the affliction lessening the ridge of the glenoid cavity and 
than women and it is found more commonly making displacement easy. 
in the relaxed type of individual. Epileptics Muscle. Occasionally the muscles support- 
are particularly subject to it. Only rarely ing the joint and holding the head against 
is there a case of double dislocation. the glenoid cavity are found torn or atrophied. 

The resulting altered muscle tension is un- 

pathology doubtedly connected with dislocation. The 

The pathology varies widely in different pectoralis major, the latissimus dorsi, and the 

individuals. teres major keep the head pressed against the 

Capsule. The most constant lesion, which glenoid surface, while the supraspinatus, in- 

may be of several varieties, is located in the fraspinatus, and the teres minor act as the 

capsule. In some cases there is actual avul- lateral rotators, and the subscapularis as the 

sion of the capsule from its attachment, while medial rotator. In a posterior dislocation, the 

in most cases it is raggedly torn, usually in its detachment or rupture of the subscapularis 

anterior and inferior parts, and stretched to a contributes to the loss of support. In cases 

point where, even in repair, an actual pouch in which the insertions of the supraspinatus 

is found on the inferior and anterior surface, and infraspinatus are torn off at the first 

As this portion of the capsule is not supported luxation, relaxation and loss of tone result, 

by muscle it is easy for the head to slip out. The teres major and latissimus dorsi then 

The pouch acts as a receptacle for the head, tend to pull the head downward and when 

when the patient's arm is abducted or ele- the muscles contract, the head slips over 

vated. the glenoid margin. 

Some operators have described a capsular- 
periosteal separation, in which the capsule 

and a part of the glenoid pad are continuous The main complaint in all cases is the fear 

with the periosteum detached from the that displacement will occur on abduction of 

scapula. the arm. This fear seriously handicaps the 

Bone. Chief among the bony abnormali- patient in any occupation that involves the 

ties that have been observed, is the defect possibility of arm elevation and is a serious 

of the humeral head. Many surgeons since obstacle in sports. 

the time of Joessel (35), Cramer (10), and The frequency of recurrence varies in differ- 

Loebker (43) have demonstrated by resec- ent cases. Some dislocations recur only once 

tions on both the cadaver and on the liv- in several months, while others may occur 

ing that the humeral head is normal in only daily. Occupation has much to do with the 

its anterior part. A wedge-shaped notch frequency. Sometimes turning in bed will 

exists on its posterior side, which is caused produce a dislocation. Fortunately cases 

by the striking of the head against the glen- that have luxated several times may be re- 

oid margin when luxation occurs. Gregoire duced easily. 

(26) considered that this groove in the head Some muscular atrophy of the coraco- 

was the main cause of recurrent dislocation, brachialis, triceps, deltoid, and especially the 

1 

Published by Surgical Pub. Co., Chicago, U.S.A. 



SYMPTOMS 



£ 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. i. An elastic surcingle. 

posterior part of the supraspinatus and infra- 
spinatus may be observed. There may be a 
slight limitation of motion, frequently in 
abduction. 

Pain is usually present just after actual 
displacement. 

The diagnosis is made purely on subjective 
symptoms, voluntary spasm, and protection 
against dislocation on any attempts at 
abduction, together with the history of recur- 
rent attacks without trauma. 

CONSERVATIVE TREATMENT 

After the initial displacement the shoulder 
is reduced and held to the side for a period of 
at least 2 weeks. In recurrent cases an elastic 
surcingle 3 to 4 inches wide is placed around 
the chest and over the affected arm several 
inches below the shoulder. This serves as a 
constant reminder and resists the abduction 
of the arm (Fig. 1). The surcingle should be 
worn constantly for 6 months, and during this 
time local therapeutic measures, baking and 
massage should be practised. If only two or 
three displacements have occurred, this 
treatment often succeeds. 

When displacement has recurred too many 
times, and especially when the displacement 
recurs only on slight exertion, conserva- 
tive treatment is of no avail. Operative inter- 
ference offers the only means of overcoming 
the difficulty. 

OPERATIVE TREATMENT 

Usual Two-day Preparation 
The arm is abducted to an angle of 90 de- 
grees with the body. The humeral head is 
then easily felt as prominent in the axilla. 
The vessels are located and a 4-inch incision 




Fig. 2. The 4-inch incision made posterior to the ves- 
sels and parallel with the arm. 



made posterior to them and parallel with the 
arm (Fig. 2). A plexus of veins is usually 
found over the head and these are cut and 
retracted. The subscapular muscle is then 
exposed directly over the humeral head. It 
may be retracted as a whole or it may be 
divided in the direction of its fibers and the 
portion overhead retracted. The capsule 
over the head is then in view, and a complete 
exposure of the capsule should be obtained. 
About halfway between the glenoid and the 
middle of the humeral head, a curved incision 
is made parallel to the glenoid. After the head 
is examined and the pathology studied, it is 
replaced. The capsule is overlapped well and 
the sutures placed, but not actually tied 
until the arm is brought down to an angle of 
about 45 degrees from the body (Fig. 4.) 
Chromic gut is usually used for this pur- 
pose. The subscapular muscle is then re- 
turned to normal and the skin closed with 
interrupted catgut No. 1. Dry dressing is ap- 
plied and the arm held at the side for 6 weeks 
without motion. Then restricted use is al- 
lowed, taking care to protect the arm from 
forced abduction for a period of 3 to 4 months 
(Fig. 2). 

REPORT OF CASES 

Case i. R. M., an epileptic suffered from dis- 
location of both shoulders. When I saw the patient 
in January, 1921, he reported that the right shoulder 



MacAUSLAND: RECURRENT DISLOCATION OF THE SHOULDER 




Fig. 3. Capsule overlapped and sutures in place. 

was dislocated about twenty times during the pre- 
vious year. Abduction of the shoulder was limited by 
spasm. The left shoulder first slipped out 4 years 
ago and dislocation had recurred about forty 
times. The left shoulder was operated on elsewhere 
twice without relief, and a third operation pre- 
vented the shoulder from slipping out again, but 
resulted in a considerable limitation of motion. 

Treatment. An operation following the technique 
described was performed on the right shoulder in 
March, 1921. Six weeks later the anteroposterior 
motions were normal and abduction was one-half 
normal. 

In June, 192 1, 3 months after intervention, the 
patient, in falling, displaced the right shoulder 
anteriorly. Another operation was done in August, 
192 1. After several falls during epileptic attacks, 
resulting in dislocation, an excision of the head 
of the humerus was done in September, 1922. 

Result. In June, 1923, when I examined the pa- 
tient, abduction of 80 degrees was possible in the 
left shoulder, rotation in adduction was normal, ro- 
tation in abduction was possible for a few degrees 
each way. There had been no recurrence. The 
patient had wrenched the right shoulder 1 week 
before. Abduction without pain was impossible 
beyond 50 degrees. A few degrees of internal and 
external rotation were possible. There was marked 
atrophy of the deltoid. There had been no recurrence. 

Case 2. E.R., dislocated his left shoulder while 
playing football in 1908. From then up to the time 
of admission to the hospital (February, 191 1) the 
shoulder was dislocated fifteen times. 

Treatment. An open reduction, using the usual 
technique was performed in 1911. 

Result. Twelve years later the patient wrote me 
that he had never had any trouble with the shoulder 
and he used it as freely as the other one. 





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Fig. 4. Capsule overlapped and sutures tied. 

Case 3. E. D., dislocated both shoulders while 
playing football in 191 2. When I saw the patient 3 
years later, the right shoulder gave no symptoms, 
but the left had slipped out repeatedly since the 
injury. The shoulder was dislocated eight times 
during 3 months, once while sleeping. 

Treatment. An operation following the usual 
technique was performed in 1915. 

Result. Up to December, 1921, there was no 
recurrence nor any disability, except for a slight 
weakness in doing heavy physical work. Late in 
December the shoulder came out once during 
gymnastic exercises. Up to the present time (June, 
1923) there has been no further trouble, but the 
patient uses the arm with caution. 

Case 4. E. L., while playing football in 191 1, dis- 
located his left shoulder. Recurrence took place six 
times after the original dislocation, often during sleep. 

Treatment. An open operation was done, follow- 
ing the usual technique. 

Result. About 9 months later the patient re- 
ported having no trouble, except that the arm was 
not as strong as the other. 

Case 5. S. S. fell from a horse in 1913 and injured 
her shoulder. Dislocation had recurred repeatedly, 
once while dancing, once while swimming. 

Treatment. An open operation following my usu- 
al technique was done in May, 19 16. 

Result. The patient wrote several years after the 
operation that she had had no trouble with the 
shoulder, although at times it felt weak. She is a 
counsellor in a camp. 

Case 6. L. R., while wrestling, dislocated his 
left shoulder and 6 months later the shoulder came 
out again. Before I saw the patient in 1915, dis- 
location had recurred fifteen times. 

Treatment. An open operation was done in which 
the capsule was quilted. 



SURGERY, GYNECOLOGY AND OBSTETRICS 



Result. Two years after the intervention, the 
patient showed a perfect result and the arm had 
never given him any trouble. 

HISTORY 

Prior to capsulorrhaphy, braces and band- 
ages were first used in treatment, but as they 
allowed only limited motion, they were 
finally disregarded. 

Hippocrates (32) tried to form a cicatrix to 
contract the joint space, by entering the artic- 
ular cavity with a red hot iron. Malgaigne 
(46) and others practised myotomy in the 
hope of producing an inflammatory condition. 

Albert (2), in 1879, first tried arthrodesis; 
he was followed by Wolff (84), Karewski 
(36), Mueller (50), and others. Cramer (10), 
in 1882, made a complete resection of the 
humeral head. There were many imitators of 
his technique, particularly in Germany. 

But all these methods were finally aban- 
doned because they resulted in diminution of 
function or were considered unsurgical. 

Capsulorrhaphy without arthrotomy. In op- 
ening the joint for resection, the dilated con- 
dition of the capsule attracted the attention 
of the operators. Several methods, with or 
without arthrotomy or capsulotomy were 
then devised to obtain a diminution of the 
capsule. Ricard (59), in 1892, first tried 
capsule reefing without opening the joint, by 
forming a permanent fold in the anterior por- 
tion of the capsule by means of three silk 
sutures placed vertically. No relapse fol- 
lowed and normal mobility resulted in two 
cases. 

Many surgeons followed his technique or 
modifications of it. Certain operators used a 
posterior incision instead of the anterior one 
Steinthal (74), Paladini (54), Mueller (50) 
Francke (22), Payr (55), Lardennois (41)' 
Nelaton (51), and Thomas (76) operated in a 
similar manner. 

Dehner (13) and Krumm (39) used a poste- 
rior vertical incision to bring the humeral 
head to the posterior cavity rim and then 
contracted the capsule at about the approach 
of the head into the rim. 

Beck (5), in 1903, plicated the capsule on 
its anterior surface and in addition carried a 
silver wire through a hole drilled in the head 
of the humerus and in the acromion. The 
wire was removed in 5 weeks. The result was 
perfect. 



Mauclaire (47) and Berger (6) modified the 
method, Berger by fixing the capsule to the 
tip of the acromion to reinforce it, and Mau- 
claire by making two plications, one vertical 
and one horizontal. 

Trethowan (77) successfully plicated the 
capsule in a case, but he found the operation 
very difficult. 

Picque's (57) method differed from Ri- 
card's in that he formed a fibrous-muscular 
capitonnage on the anterior face of the joint 
by passing three sutures of horsehair or silk 
through the capsule. He discriminated be- 
tween the cases in which there was a swelling 
of the capsule and those in which there was a 
notch in the humeral head and a capsular- 
periosteal separation. In the latter cases, 
resection followed capsulorrhaphy. De Four- 
mestraux (21) made the same discrimination. 

Legueu (42) relieved an epileptic patient by 
reefing the capsule with horsehair. Three 
months after the operation, the patient fell, 
causing a new luxation. Picque (57) used his 
method on the case and obtained a successful 
result. 

Bliss (7), in 1906, tightened the capsule in a 
case in which there had been fifty recurrences, 
by means of including an elliptical portion in 
silk strand sutures. A perfect result was ob- 
tained. 

In 1908, Stimson (75) used Ricard's method 
successfully, making a permanent fold by 
means of three silk sutures placed vertically. 
Meyer (48) used the same procedure in one 
case. 

The same year, Dahlgren (n) traced the 
efficacy of simple capsule contraction and 
found there had been no relapse in twenty- 
five of the forty-one cases which he collected 
from literature. All of these cases had not 
been due to the enlargement of the capsule, 
but to other causes such as the tearing off of 
the muscles, especially the outward rotators. 

Wilmanns (82) had two interesting cases in 
which he obtained perfect cures through 
simple interference and contracture. 

Kosloff (37) herself, suffered from a recur- 
rent dislocation of the shoulder. She was 
operated on by Duval, who sutured the cap- 
sule vertically with linen thread. The pa- 
tient, after 4 years, used the arm with the 
same facility as the sound one. Kosloff be- 
lieved capsulorrhaphy was justified in cases 



MacAUSLAND: RECURRENT DISLOCATION OF THE SHOULDER 5 

where, aside from the laxity of the capsule, that the anterior inferior portion of the capsule 

there existed a capsular tear, a capsular- is torn and as this portion is unsupported by 

periosteal separation, or a lesion of the an- muscular insertions, recurrence is easy. There- 

terior edge of the glenoid. fore, this section of the capsule was strength- 

Walther (78), in 1918, plicated the capsule ened. In some cases the pectoralis major was 

by means of three horsehair sutures passed lengthened. The condition of sixteen pa- 

from the inner side outward through the tients was decidedly improved; 50 per cent 

entire length of the capsule. His patient of these were cured. It was too early to report 

could pursue his occupation, although there on the other three cases, 

was some limitation of motion. Of a group of eight patients on whom he 

Riviere (61) secured a perfect result by reported in 191 7, one had dislocation nearly 6 

suturing the capsule and fixing it to the years after the operation and another patient 

subscapularis without opening the joint. had relapse in 5 years. Both, however, were 

Durand (17), in 1919, reported a case in better than before the operation, 

which he made a vertical and horizontal fold Dreesmann (15), Goldmann (25), Wilmanns 

in the capsule. No relapse followed and the (82), Samosch (63), Hildebrand (31), and 

patient had normal motion. Schultze (67) tried capsule doubling or rein- 

Capsulorrhaphy following arthrotomy. As forcing. Wiesinger (81) used the incision of 

these methods did not permit the exploration the capsule and tamponade to secure reduc- 

of the joint, which several surgeons believed tion. 

to be important, Samter (64) and Mikulicz Capsulorrhaphy after excision. The first 

(49) then recommended the splitting of the capsulorrhaphy after excision was tried by 

capsule vertically and the drawing of the Gerster (23) in 1883. He removed a piece of 

medial part over the lateral part. capsule by a semi-elliptical incision and united 

Grothe (27) incised the anterior portion of the capsular wall, as well as the muscles and 

the capsule and narrowed it by overlapping skin, by three tiers of interrupted catgut, 

the edges of the incision. The patient was cured. 

MacKinnon (45), in 1907, in the case of a Bardenheuer (4), in 1886, excised two pieces 
farmer whose shoulder dislocated frequently of capsule, and secured good results, 
in sleep, introduced mattress sutures into one In 1895, Burrell and Lovett (8) removed an 
margin of the incised capsule and tied the elliptical piece and sutured the capsule to 
sides in such a way that one flap came under shorten it. A second case was reported in 
the other. The patient made a complete re- 1897. They believed it important to divide the 
covery. In discussion of this report, Dr. tendon of the insertion of the pectoralis ma- 
Wright said he had successfully quilted the jor for three-fourths its breadth, to allow 
capsule transversely in the case of an epileptic uncovering the capsule, 
patient. Warren (79), Dawborn (12), Baldwin (3), 

Steeg (73), in 1910, reported a case in and Albee (1) secured good results using 

which, after exploration of the joint, he in- Burrell and Lovett's procedure, 

troduced four sutures of catgut vertically into Mueller (50), Haegler (28), Kuh (40), 

the capsule. The result was successful; the Kronacher (38), Goldmann (25), and Donati 

patient had full function of his arm. (14) reported cases in which they excised 

Schultze (67) in his operation, after blunt pieces of the capsule. Some surgeons com- 

dissection of the deltoid on the outside, freed bined the methods of Gerster and Mikulicz, 

the capsule and drew the edges of the wound Between 1909 and 192 1 Thomas (76) 

one over the other. In this way he doubled issued several reports summarizing his cases 

the anterior capsule. and describing his technique. The capsule 

Worcester (85) overlapped the edges of was contracted by sutures, by overlapping, 

the capsule in three patients, with successful or by excision. At first he used an anterior 

results. axillary incision, but later recommended the 

Henderson (29), in 1921, issued a report of posterior route, as he found the capsule could 

nineteen cases treated in the Mayo Clinic, be approached more easily in this way. Also 

The method used was based on the principle the wound was smaller, and motion returned 



6 SURGERY, GYNECOLOGY AND OBSTETRICS 

more rapidly. In the cases in which the used this method in connection with capsular 

method of excision was employed, Thomas plication. 

allowed cicatrization across the gap made in Seidel (68), in 1913, reported a case in 

the capsule, then contracted the portion to which he separated the subscapularis muscle, 

within normal length, and stretched it by took out an oval piece of capsule and sutured 

suitable exercises. In all cases he found the edges of the capsule together. He then 

evidence of wearing in the posterior part of covered the entire front of the joint with a 

the head and glenoid. In some it was neces- piece of transplanted fascia and sutured it to 

sary to do a partial excision of the head. the deltoid and subscapularis. The patient 

Because of this wearing, which will prevent died some time later and examination showed 

complete return of the joint to normal, the flap had been preserved. Payr (55) also 

Thomas considered the terms of success only reported one case using this technique, 

relative. In 192 1, he issued a report covering Schultze (67) was of the opinion the fascia 

the accumulation of 4 years' observations, flaps were necessary. 

Of forty-four shoulders which he had treated, Still others reduced the capsule and 
eighteen had been epileptic cases. There had sutured the outward rotators. These opera- 
been no dislocation in eleven cases after tions treating the muscles are chaotic. Muel- 
capsulorrhaphy, done in the most recent ler (50) tried to revise the external rotators 
case 4 years before the time of the report, and at their appendage behind the deltoid or 
in the first case 11^ years before. Another subscapularis. 

case had been successful after excision of part Perthes (56) twice used reefing of the cap- 
of the humeral head. Three were failures, sule and firm fixing of the torn external ro ta- 
in the non-epileptic group, there were tors on the great tuberosity. In the four cases 
twenty-two successful cases after capsulor- reported, he varied his technique, according 
rhaphy, done in the first case 13 years before, as the muscles were torn, the cavity rim 
and in the last case 3 months before. There broken, or the capsule dilated. If the muscles 
were two failures. were torn from the tuberculum ma jus, he 

Capsulor rhaphy plus treatment of other replaced their insertions on the head of the 

lesions. Some surgeons did not consider humerus by means of V-shaped nails. The 

capsulorrhaphy sufficient as they found other tendons were nailed directly to the bony 

lesions present and believed it necessary to do surface or attached to the bows of the nails 

a simultaneous operation to give the joint with silk. If the glenoid rim was torn, it also 

support. could be fixed by means of V-shaped nails 

Winiwater (83), in 1905, presented a young driven into the neck of the scapula, 

man on whom he had operated 2 years before. Hildebrand's (31) operation was concerned 

One incision was made along the upper edge with the changes of the joint cartilage. He 

of the clavicle, and a second made obliquely deepened the cavity with a sharp curette, and 

between the major pectoralis and the deltoid thus obtained a prominence of the medial 

muscle. Two folds were made in the capsule glenoid edge. 

by means of sutures. Then, to oppose dis- Besides capsulorrhaphy, other methods were 

location of the head, he united the upper edge tried, some to change the tension of the di- 

of the subscapularis to the lower edge of the lated capsule or others to construct a liga- 

minor pectoralis by a series of sutures, thus ment to hold the joint in place, 

stretching the two muscles over the capsule. Roepke (62) reefed the tendon of the sub- 

The major pectoralis was returned to its place scapularis muscle to secure better support 

and sutured at its clavicular and deltoid in- around the capsule. This was handled by an 

sertion. The functional result was excellent; incision on the outside axillary border, 

in 4 months the pati°nt had complete use of Selig (69) proposed reefing the supraspinatus 

his arm. tendon as he considered this muscle played an 

Other surgeons strengthened the capsule by important part in dislocation. Sever (71) rec- 

nailing the head of the biceps on the lesser ommended suturing the subscapularis ten- 

tuberosity to strengthen the restraining ap- don and dividing the pectoralis major tendon, 

paratus in front of the joint. Werndorff (80) Capsulorrhaphy may be performed in con- 



MacAUSLAND: RECURRENT DISLOCATION OF THE SHOULDER 



nection with these steps, but it is not neces- 
sary. Complete revision of the pectoralis 
major was done in forty cases. There were no 
relapses or loss of motion. 

Joseph (34) used fascia lata strips to con- 
struct a ligament that would prevent luxation 
of the head. In two cases, the results were 
satisfactory and motion, which he had feared 
might be lost, was good. Schmieden (66) also 
secured a favorable result by this method. 

Semken (70) made a vertical incision 1 inch 
external to the anterior border of the deltoid. 
A tunnel was made under the subscapularis 
and a graft of fascia lata from the thigh drawn 
through and its upper end fastened with 
interrupted catgut sutures to the upper part 
of the capsule and its lower end to the sub- 
scapular head of the triceps muscle. This 
flap thickened and contracted and hindered 
the anterior excursion of the humeral head. 

Loeffler (44), Sandes (65), and Herforth 
(30) advocated fascia flaps to gain security. 
Evatt (19) recommended a silk cord to 
connect the humerus and the axillary border 
of the scapula. 

Treatment of muscular contraction Several 
surgeons believe that operation should be 
directed to the relief of the disturbance of the 
co-ordination in the muscular contraction. At 
the surgical congress in Germany in 1909, 
Clairmont and Ehrlich (9) proposed a new 
method — myoplasty — to struggle against the 
action of the deltoid. The opposing muscular 
traction was obtained through the formation 
of a flap on the inner portion of the deltoid 
muscle which was passed from behind for- 
ward under the neck of the humerus, and its 
end sutured to the same muscle in front. 
This flap acted as a sling to hold the joint in 
place. 

Clairmont reported four cases; Major Dunn 
(16), one case; Piatt (58), one case; and 
Thomas (76), three cases. Only one of these 
cases (Clairmont's) relapsed. Seven cases 
by Gibson (24) gave favorable results. 

R. Jones (33), in 191 2, is reported to have 
done two of these operations. The flap was 
carried through the quadrilateral axillary 
space and fastened to make a sphincterlike 
ring about the neck of the humerus. Im- 
mobility for 2 months followed. One case re- 
curred from lack of immobility or insufficient 
fixation of muscle. The second was a success. 



Finsterer (20) secured satisfactory results 
in seven cases, using muscle flaps. Olleren- 
shaw (52) advocated this procedure. 

Other surgeons attempted the division of 
the tendon of the subscapularis muscle. 
Spencer (72) reported one successful case and 
Openshaw (53), three satisfactory cases. 

Another type of operation was based on 
changing the leverage of the two powerful 
muscles which act as the dislocating force. 
Young (86) was the advocator of this method, 
which was suggested by Allis. The incision 
was made in the space between the deltoid 
and pectoralis major muscles. The attach- 
ment of the latter muscle was divided at its 
lower half. Through a second incision the 
latissimus dorsi muscle was reached and the 
lower half divided. The arm was put in wide 
abduction for 10 days. 

Eden (18) found that in many cases the 
tearing of the capsule with bone from the 
cavity rim was ground for the return of the 
luxation. In these cases, he considered that 
capsule reefing, suturing of the external ro- 
tators or muscle plastic, could not prevent 
recurrence. The joint capsule must be fas- 
tened into position and the shape of the cavity 
restored. This was obtained by building a 
hindrance of a piece of bone from the tibia. 
The torn capsule was fastened in its old 
place by sutures. Two patients have had no 
relapse after 3 years. 

CONCLUSION 

From a study of the literature of this sub- 
ject, it appears that the treatment of recurrent 
dislocation of the shoulder has been one of 
varying technique. No consistent method, 
adaptable to a large number of cases, has been 
reported. On the contrary, each treatment 
differs according to the importance attributed 
by the surgeon to the pathological condition 
of the bone, capsule, and muscle. The ma- 
jority of cases have been treated by some form 
of capsulorrhaphy, and in most of them satis- 
factory results have been obtained. 



BIBLIOGRAPHY 

1. Albee. Am. J. Surg., 1908, xxii, 210. 

2. Albert. Intern, klin. Rundschau, 1888, No. 9. 

3. Baldwin. Ohio M. J., 1907-08, iii, 161. 

4. Bardenheuer. Deutsche Chir., 1886, lxiiia. 

5. Beck. New York M. J., 1903, lxxviii, 64 



6. Berger. Bull. Soc. de chir., 1905. 



SURGERY, GYNECOLOGY AND OBSTETRICS 



IO. 

II. 

12. 

*3- 

14. 

IS- 
16. 

17- 
18. 
19. 
19. 

20. 

21. 

22. 

23- 

24. 

25- 

26. 

27. 
28. 



29. 

30. 

31- 

32. 

33- 

34- 

35- 
36. 

37- 

38. 

39- 

40. 
41. 

42. 

43- 
44. 

45- 
46. 



Bliss. J. Roy. Army M. Corps, London, 1906, vii, 

5°7- 
Burrell and Lovett. Am. J. M. Sc, 1897, Aug. 
Clairmont and Ehrlich. Wien. klin. Wchnschr., 

1917, xxx, 1507. 
Cramer. Berl. klin. Wchnschr., 1882, p. 21. 
Dahlgren. Nord. med. Ark., 1908, i, 33. 
Dawborn. Reported by Baldwin, Ohio M. J., 1907- 

08, hi, 161. 
Dehner. Muenchen. med. Wchnschr., 1889, No. 5, 

165. 
Donate Bull. d. sc. med. di Bologna, 1907, vii, 201. 
Dreesmann. Muenchen. med. Wchnschr., 1900, No. 

19, 650. 
Dunn. Reported by Thomas. Surg., Gynec. & Obst., 

1921, xxxii, 291. 
Durand. Lyon chir., 1919, xvi, 404. 
Eden. Deutsche Ztschr. f. Chir., 1918, cxliv, 268. 
Idem. Zentralbl. f. Chir., 1920, xlvii, 1002. 
Evatt. Dublin J. M. Sc. inch Tr. Roy. Acad. Med., 

Ireland, 1921, 4. s., 161. 
Finsterer. Muenchen. med. Wchnschr., 1917, lxiv, 

360; Deutsche med. Wchnschr., 191 7, xliii, 800. 
de Fourmestraux. Bull, et mem. Soc. anat. de Par., 

1906, lxxxi, 433; 671. 
Francke. Deutsche Ztschr. f. Chir., 1898, xlviii, 399. 
Gerster. New York M. J., 1884. 
Gibson. Canadian M. Ass. J., Toronto, 1921, xi, 

194. 
Goldmann. Zentralbl. f. Chir., 1909, No. 12, 429. 
Gregoire. Rev. d'orthop., Par., 1913, 3. s., iv, 15. 
Grothe. Muenchen. med. Wchnschr., 1900, No. 19. 
Haegler. Reported by Finsterer. Muenchen. med. 

Wchnschr., 1917, lxiv, 360. Deutsche med. 

Wchnschr., 191 7, xliii, 800. 
Henderson. Surg., Gynec. & Obst., 1921, xxxiii, 1. 
Herforth. Zentralbl. f. Chir., 1922, xlix, 1140. 
Hildebrand. Arch, f . clin. chir., 1902, Ixvi, 360. 
Hippocrates. The Genuine Works of Hippocrates, 

translated by F. Adams. 1886, ii, 95. 
Jones, R. Reported by Armour. Liverpool Med.- 

Chir. J., 1914, xxxiv, No. 65, 100. 
Joseph. Berl. klin. Wchnschr., 1917, liv, 525; 1919, 

lvi, 779. 
Joessel. Deutsche Ztschr. f. Chir., 1874, iv, 124. 
Karewski. Reported by Donati. Bull. d. sc. med. 

di Bologna, 1907, 8. s., vii, 201. 
Kosloff. Contribution a l'etude de la luxation re- 
cidivate de l'epaule. Paris, 1911, Jouve & Cie. 
Kronacher. Reported by Finsterer. Muenchen. 

med. Wchnschr., 1917, lxiv, 360. Deutsche med. 

Wchnschr., 191 7, xliii, 800. 
Krumm. Muenchen. med. Wchnschr., 1899, No. 30, 

986. 
Kuh. Prag. med. Wchnschr., 1903, xxviii, 599. 
Lardennois. Union med. du nord-est, Reims, 1905, 

xxix, 125. 
Legueu. Bull, et mem. Soc. de chir. de Par., 1905, 

n.s. xxxi, 573. 
Loebker. Klin. Chir., 1887, xxxiv, 657. 
Loeffler, T. Zentralbl. f. Chir., 1920, xlvii, 324. 
MacKinnon. Med. Herald, 1904, xxiii, 566. 
Malgaigne. Traite des Luxations. 



47. Mauclaire. Bull, et mem. Soc. de chir. de Par., 1905, 

xxxi, 10. 

48. Meyer. Ann. Surg., 19 18, May, 811. 

49. Mikulicz. Beitr. f. klin. Chir., 1896. 

50. Mueller. Ueber habituelle Schulterluxation. 27. 

Chirurgencongress. Berlin, 1898. 

51. Nelaton. Traite de Chirurgie. Duplay et Reclus, 

1897, iii. 

52. Ollerenshaw. J. orthop. Surg., 1920, ii, 255. 

53. Openshaw. Proc. Roy. Soc. Med., Lond., 1907-08, 

i, Clin. Sect., 29. 

54. Paladini. Riforma med., 1895. 

55. Payr. Reported by Finsterer. Deutsche Ztschr. f. 

Chir., 1917, cxli, 354. 

56. Perthes. Deutsche Ztschr. f. Chir., 1906, lxxxv, 199. 

57. Picque. Bull, et mem. Soc. de chir. de Par., 1905, 

xxxi, 564; 963. 

58. Platt. Reported by Thomas. Surg., Gynec. & Obst., 

1921, xxxii, 291. 

59. Ricard. BulldePAcad. deMeU, 1892. These Boula- 

kia. 

60. Rich. Northwest med., 1917, xvi, 114. 

61. Riviere. Lyon chir., 1918, xv, 437. 

62. Roepke. Verhandl. d. deutsch. Gesellsch. f. Chir., 

Berl., 1912, xlii, 351. 

63. Samosch. Beitr. z. klin. Chir., 1896, xvii, 803. 

64. Samter. Arch, f . klin. chir., 1900, lxii, 115. 

65. Sandes. Brit. M. J., Lond., 1921, ii, 321. 

66. Schmieden. Reported by Joseph. Berl. klin. 

Wchnschr., 1919, lvi, 779. 

67. Schultze. Arch. f. klin. Chir., Berl., 1914, civ, 138. 

68. Seidel. Zentralbl. f . Chir., 1913, No. 34, 1344. 

69. Selig. Deutsche Ztschr. f. Chir., 1915, cxxxii, 581. 

70. Semken. Med. Rec, N. Y., 191 7, xci, 435. 

71. Sever. J. Am. M. Ass., i92i,lxxvi, 925. 

72. Spencer. Proc. Roy. Soc. Med., Lond., 1909-10, 

iii, Clin. Sect., 20. 

73. Steeg. Rev. med. de Normandie, Rouen, 1910, 62. 

74. Steinthal. Wuertemberg. Corres.-Bl., 1895. 

75. Stimson. Fractures and Dislocations. 1917,678. 

76. Thomas. J. Am. M. Ass., Chicago, 1910, liv, 834. 

Internat. Clin., Phila., 1910, ii, 277. Am. J. M. Sc, 
1909, cxxxvii, 299; 367. Univ. Penn. M. Bull.. 
1909-10, xxii, 16. Surg., Gynec. & Obst., 1914, 
xviii, 107. Ann. Surg., 192 1, lxxiii, 639. Surg., 
Gynec. & Obst., 1921, xxxii, 291. 

77. Trethowan. Reported by Thomas. Surg., Gynec. & 

Obst., 1921, xxxii, 291. 

78. Walther. Bull, et mem. Soc. de chir. de Par., 1918, 

xiiv, 48. 

79. Warren. Boston M. & S. J., 1903, cxlviii, 285. 

80. Werndorff. Ztschr. f. orthop. Chir., 1907, xix, 224 

81. Wiesinger. Deutsche med. Wchnschr., 1895, Ve- 

reinsbeilage No. 17, 116. 

82. Wilmanns. Zentralbl. f. Chir., 1909, xxxvi, 429. 

83. Winiwater. Ann. Soc. med.-chir. de Liege, 1905, 

xliv, 134. 

84. Wolff. Reported by Donati. Bull, delle sc. med., 

Bologna, 1907, 201. 

85. Worcester. Med. Rec, N. Y., 1920, xcviii, 80. 

86. Young. Ann. Surg., 1916, lxiii, 375. Interstate M. J., 

St. Louis, 1916, xxiii, 312. Am. J. Orthop. Surg., 
1913, xi, 243. 



Extracted from the American Journal of the Medical Sciences, 
January, 1925, No. 1, vol. clxix, p. 1 



INJURIES TO THE MUSCULOSPIRAL NERVE. 
By W. Russell MacAusland, M.D., 

SURGEON-IN-CHIEF, ORTHOPEDIC DEPARTMENT, CARNEY HOSPITAL. 

AND 

Andrew R. MacAusland, M.D., 

ORTHOPEDIC SURGEON, CARNEY HOSPITAL, BOSTON, MASS. 



The musculospiral nerve is frequently involved in injuries of 
the upper extremity, due largely to the close approximation of the 
nerve to the shaft of the humerus in its middle third, von Busch, 10 
in 1863, was the first to describe the paralysis resulting from injury 
of the musculospiral nerve in fractures of the humerus. Since his 
discovery many attempts have been made to restore the anatomical 
continuity of the nerve. In the World War, operative procedures 
were used with an appreciable measure of success in cases of paralysis 
of the musculospiral nerve resulting from wounds or fractures. 

Slight injuries to the musculospiral nerve are frequently over- 
looked, especially as the paralytic symptoms may disappear rapidly 
after reduction of the fracture. In some cases, however, paralysis 
follows injury to the nerve trunk, due to the original trauma or to 
subsequent pressure upon the nerve from bony callus or scar tissue. 
These injuries demand early recognition and treatment, for such 
damage unrecognized often leads to a serious loss of function. 

Very little has appeared in American literature on this important 
subject. It is our purpose to review the literature, particularly 
that of foreign countries, and to present our personal experiences 
with several of the more severe types of these injuries. 

Anatomy of the Nerve. The musculospiral nerve is the principal 
continuation of the posterior cord of the brachialis plexus, and the 
only branch prolonged into the arm. It arises behind the axillary 
vessels, turns backward with the superior profunda artery between 
the long and internal heads of the triceps, and runs beneath the 
external head of the muscle in the musculospiral groove of the 
humerus, to the outer side of the arm. It pierces the external 
intermuscular septum, and descends between the brachialis anticus 
and the supinator longus to the front of the external condyle, where 



2 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

it divides into the radial and posterior interosseous nerves. The 
radial is a cutaneous nerve, supplying the outer side of the thumb 
and the skin of two and a half fingers. The posterior interosseous 
supplies all the muscles on the back of the forearm except the 
anconeus. 

The branches of the musculospiral nerve, arising on the inner side 
of the humerus, consist of the muscular branches supplying the 
long and inner heads of the triceps, and the internal cutaneous 
branch which passes backward beneath the intercosto-humeral 
nerve and supplies filaments to the skin over the long head of the 
triceps. The posterior branches of the musculospiral nerve consist 
of a fasciculus of muscular branches which supply the outer and 
inner heads of the triceps muscle and the anconeus. The external 
branches consist of the external cutaneous branches and the muscular 
branches. The external cutaneous branches distribute filaments 
to the lower half of the arm on its outer and anterior aspect and the 
branch descending to the wrist distributes offsets to the lower half 
of the arm and forearm, on their posterior aspect. The muscular 
branches supply the supinator longus, the extensor carpi radialis 
longior and frequently a small branch to the outer part of the 
brachialis anticus (Quain 63 ). 

Symptoms. The symptoms of injury to the musculospiral nerve 
vary in degree and duration according to the severity of the trauma 
and the resultant pathology. If, in a fracture of the humerus, the 
pressure on, or the stretching of the nerve is slight, any symptoms 
traceable to nerve injury may disappear in a few minutes. If 
continuity is interfered with, certain motor and sensory changes make 
their appearance. 

Motor Changes. The wrist drops and the power of extension 
of the hand is lost. The hand is held pronated and half-flexed with 
the palmar surface slightly concave. If the hand is placed on a 
resistant surface, the lateral movements are impossible. If this 
deformity has existed for some time, there is a marked prominence 
on the dorsum of the hand, due to the stretching of the dorsal liga- 
ment of the wrist and the subluxation of the carpus. Extension 
of the fingers at the metacarpophalangeal joints as well as extension 
of the terminal phalanx of the thumb is lost. 

The forearm is half -flexed and no extension is possible at the elbow. 
Supination is entirely lost when the forearm is extended on the arm, 
but if the forearm is flexed, a moderate degree of supination is 
possible through the action of the biceps. 

Sensory Changes. There may or may not be any loss of sensibility. 
The area of loss when the nerve is divided extends roughly over the 
dorsum of the hand and lower wrist. There is no loss of sensibility 
in the forearm beyond a slight impairment of a very small area to 
the faradic current, and even this is doubtful. 



MAC ATJSLAND, MAC AUSLAND : THE MITSCULOSPIRAL NERVE 3 

Several theories have been expounded to explain the slight changes 
in sensibility. Letievant 45 attributes it either to the abundant 
anastomoses between the median and ulnar nerves which undertake 
regeneration when the radial nerve is injured, or to the newly-formed 
nerve fibers from the uninjured parts which grow into the anesthetic 
region and produce regeneration. Fessler 24 does not support this 
theory, but believes the fibers of the radial are important in the 
retention of the sensibility. 

Pain. In complete division of the nerve no pain is experienced. 
If the nerve is injured or compressed by organized callus or scar 
tissue, the sensation of pain is most evident a few days after the 
injury. 

Clinical Examination. In determining the extent of the injury 
it is necessary to obtain a careful history of the accident and symp- 
toms, as well as to examine the injured parts and test all muscle 
groups and sensory areas. 

If possible, it should be decided whether the nerve is completely 
divided or merely traumatized. The function may be lost below 
the seat of the injury, either because the nerve has been divided, 
traumatized, or compressed by callus. It is frequently difficult 
to judge the exact condition, particularly if the injured part is 
examined immediately after the accident, when the symptoms are 
severe. In such cases, the sensory examination is very frequently 
ineffective as numerous anastomoses exist in the hand, and the 
maximum puncture may be of no value. An electrical excitability 
test does not give deciding data, as it is rendered difficult through 
swelling, and excitability of the peripheral nerves may still be possi- 
ble. The presence of motor signs may be of no value, as they may 
show remaining power or may indicate the beginning of repair. 

Muscles. All the muscles supplied by the musculospiral nerve 
should be tested for movement, tone, reflexes and atrophy. The 
power of the extensors of the wrist should be tested with the fingers 
flexed on the palm, as any slight contraction in the extensors of the 
wrist may then be felt. The extension of the proximal phalanges 
should be noted. The extension of the thumb must be carefully 
distinguished from the movement of abduction, the latter being 
controlled by the median nerve. If the examiner discerns a slight 
trace of movement, spontaneous recovery may be expected. 

Electrical Diagnosis. In making the electrical examination, the 
use of the Victor Multi-plex Sinusoidal apparatus with a diagnostic 
electrode and 6 by 8-inch disbursing indifferent electrode is recom- 
mended in the U. S. A. Manual of Neuro-Surgery. The indifferent 
electrode is moistened and placed over the abdomen or back. The 
diagnostic electrode is applied over the motor point of each muscle 
to be tested. Sufficient current is used to obtain a contraction but 
not enough to stimulate the adjoining muscles. The patient lies 



4 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

relaxed. The faradic current is first used if a normal reaction to 
electrical stimuli is obtained. The presence of faradic irritability 
after ten to fourteen days means that the nerve will recover sponta- 
neously, since it shows at once that reaction of degeneration is not 
present. If faradic irritability is diminished, then galvanic current 
is used and the speed of muscle contraction and the amount of cur- 
rent required, are noted. A feeble, sluggish contraction is an indica- 
tion that the nerve has degenerated. A brisk galvanic reaction, 
even though faradic excitability is absent, is an indication to adopt 
an expectant line of treatment. 

Skin. Methods for the examination of the sensory conditions 
have been outlined in the U. S. A. Manual of Neuro-Surgery. The 
epicritic sense is tested by shaving the skin and turning a camel's- 
hair brush over it. The protopathic sense is tested with a sharp 
pin on the end of a 6-inch stick. Deep sensibility is determined by 
the pressure of a pencil. It is rarely that some definite area of 
sensibility is not found following lesions of the musculospiral nerve. 

Hamilton 32 studied 55 cases at the Walter Reed Hospital to deter- 
mine the areas of sensibility to pressure, pin-prick, and cotton 
or camel's-hair touch. He found that the patient fails to recognize 
subjectively and with any degree of accuracy the area of sensory 
loss, especially of the epicritic sense. Twenty-seven cases showed 
a definite area of sensory involvement in the forearm and hand. 
There was only 1 case in which the musculospiral nerve had been 
injured sufficiently high to produce loss of sensation corresponding 
to all three branches. 

Vasomotor and trophic changes in the condition of the skin, nails, 
muscles, joints and bones should also be noted. 

Types of Injuries. Injuries to the musculospiral nerve may be 
divided into two groups. 

1. Immediate loss of function from traumatism. 

2. Loss of function from pressure, callus, or scar tissue, usually 
associated with fractures, and occasionally following crushing 
injuries. 

In primary division the onset of the paralysis is sudden. In 
secondary cases the paralysis develops insidiously and the functional 
loss increases as compression takes place. In case of injury coin- 
cident with or immediately following a fracture, the nerve may be 
bruised, stretched, compressed between the bone fragments or 
impaled by a spicule of bone. The nerve may be completely divided 
or the fibers may be crushed without damage of the nerve sheath. 
Goldstein 29 found 12 cases of complete division out of 20 cases of 
paralysis due to injury at the time of fracture, and he believes that 
complete division usually occurs at the time of primary injury. 

Complete division of the nerve results from fractures or from direct 
injuries such as occur in stabbing accidents. Such cases should 



MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 5 

be sutured as soon as possible. This type is illustrated by the fol- 
lowing case. 

Case I. In the course of a fight this patient, T. G., had been 
stabbed in the right arm. Two months later he began to notice 
that he could not close his hand or pick up things. When we first 
saw him, four months after the injury, he had right wrist-drop, 
no sensation in the posterior radial side of the hand, and no power 
in the supinator longus or extensor groups. Operative interference 
was advised. 

Operation. After a careful preparation, a 5-inch incision was 
made on the outer side of the arm. Upon exposure of the nerve, 
the upper end revealed a bulb almost as large as the end of the little 
finger, and the lower end was entirely separated and involved in 
scar tissue. By means of a safety-razor blade, f of an inch was 
removed from each end. The nerve sheath was sutured with inter- 
rupted linen, and the nerve surrounded by fat. The muscles were 
sutured together loosely. The skin was closed with silkworm gut 
and the arm strapped in 45° flexion. A hyperextension splint was 
applied to the forearm and hand. This position was maintained 
for three months. 

Six months after operation, power began to return in the wrist. 
Baking, massage and gentle movements were advised. Fourteen 
months after the operation, Dr. Earle E. Hussey, of Fall River, 
examined the patient and sent the following report: 

At the elbow-joint, all motions were free and unlimited. The 
muscular power to flex and extend the forearm was very good. 
The patient complained of an aching sensation in the upper third 
of the forearm, but there was neither tenderness nor loss of sensation. 

At the wrist-joint, the patient could move the hand freely in all 
directions. He could dorsiflex the wrist and had good power in the 
flexor and extensor muscles. 

The Fingers. He could make a good fist; his hand grip was 
about one-half power. The power of flexion and extension was good. 
The terminal joints of all four fingers were stiff; all the other joints 
were free. 

Loss of function may occur from hemorrhage which has become 
organized into scar tissue, which in turn involves the nerve and 
constricts the trunk. 

Case II. B. M., hurt her arm in an automobile accident in 
November, 1921. She suffered a deep muscle injury about 4 
inches above and anterior to the external condyle. The wound 
healed in three weeks, but the patient was unable to dorsiflex the 
wrist and fingers. She was seen from the first time on December 



6 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

27, 1921. There was a deep adherent scar, and considerable numb- 
ness over the lower external humeral region. The biceps and 
triceps were present and the patient could make a fist. There was 
no power in extension of the wrist or fingers, in spite of their having 
been held in hyperextension for six weeks. The patient had 
suffered also a fracture of the left clavicle and numerous other 
injuries. She was advised to enter the hospital for an exploratory 
operation. 

Operation. January, 1922: After a careful preparation, the 
musculospiral nerve was exposed by a curved incision. The nerve 
was found to pass through scar tissue that had developed at the 
site of the wound. This scar tissue was excised and the nerve thor- 
oughly freed. It was found intact and there was no bulbous end. 
The nerve was placed in a new muscle bed. The arm was kept at a 
right angle without motion for eight to ten weeks. The temperature 
remained normal. The wound was dressed for the first time on the 
fifth day. Seven weeks after the operation the patient was measured 
for a hyperextension splint for the fingers. 



ft 


1//, 




f 




V 

i jJi* 


^H^ li 



Fig. 1. — Case II. B. M. Showing return of voluntary power in extension of wrist 
and fingers, one year and three months after freeing nerve from scar tissue. 



April 18, 1922. There was slight power in the extensors of the 
wrist. 

May 16, 1922. The patient had regained power in the extensors 
on the radial side, but not on the ulnar. There were 20° of motion 
in flexion and limited extension in the elbow-joint, and it was 
expected that these motions would increase. The patient was 
advised to continue massage. 

August 4, 1922. The arm was greatly improved. The extensor 
return, except the extensor pollicis, was very good. Patient was 



MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 7 

advised to continue wearing the splint and to exercise the fingers 
daily for fifteen minutes. 

September 6, 1922. The restoration of muscle control in the 
wrist was complete except for the extensor of the first metacarpal. 
The brace was discarded. 

March 20, 1923. One year and two months after the operation, 
there was perfect flexion and extension at the elbow, good supination 
and pronation, and complete return of the musculospiral nerve dis- 
tribution. The patient could separate the fingers. The thumb and 
index finger were slightly numb and the hand showed a little atrophy 
of the thenar eminence. The patient could not make a strong grip. 
(Fig. 1.) 

Loss of function from pressure occurs following fractures of the 
humerus in which the nerve root is usually enveloped by callus or scar 
tissue that forms about the site of the fracture or injury. 

Case III. This was a case (J. L.) of injury to the musculo- 
spiral nerve following a comminuted fracture at the middle and the 
lower end of the left humerus with non-union. The nerve was 
compressed and caught in callus and scar tissue. 

October 4, 1921. One year and six months after the injury, 
the patient was seen for the first time, and advised to have an imme- 
diate operation. 

Operation. A lateral incision was made, exposing the field of 
non-union. The upper end of the musculospiral nerve where it 
enters the groove was located and dissected free from the groove 
for a short distance. As it then entered dense scar tissue it was. 
necessary to locate the lower end of the nerve which was dissected 
upward from below. This lower end also entered the scar tissue,, 
and it was only by careful and tedious dissection that the nerve 
was freely removed from this area without damage. (Fig. 2.) 

The nerve was carefully examined and although there were a 
few areas of local swelling, no definite division had taken place, 
and there were no bulbous masses within the sheath. 

The area of non-union was then explored and a graft removed 
from the tibia, was inserted and held in the humerus by kangaroo 
suture. A new bed was made for the musculospiral nerve and the 
wound closed. 

A plaster was applied from the fingers over the shoulder and 
about the chest. The wrist was held in hyperextension. 

January 24, 1922. As the radiogram showed no union, the cast 
was not removed. 

March 27, 1922. Callus formation was beginning and the graft 
was firm. The plaster was taken off (now six months), but protec- 
tion was continued. 

January 22, 1924. Union was solid. The shoulder was normal. 



8 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

Flexion and extension were perfect. Supination was limited a 
few degrees. The patient could make a fist, but the fourth and 
fifth fingers were contracted at the second phalangeal joints. There 
was complete regeneration of the extensor control. The patient 
was back at work and had a very functional hand. 




Fig. 2.— Case III. J. L. 



Showing area of non-union with musculospiral nerve 
caught in cicatricial tissue. 



Prognosis. In general, operative results have been satisfactory. 
Kramer 43 reported 35 cases with only 3 poor results. Blenke 5 
reported 58 cases, 41 of which made complete recovery, 6 partial 
recovery, 8 improved, and 3 showed little improvement. In 
some cases failures have been due to neglect of aseptic requirements 
or to lack of postoperative care. 

Surgeons disagree as to whether recovery is better after nerve 
suturing for primary injuries, or following operation for paralysis 
due to the involvement of the nerve in scar tissue or callus formation. 
Sherren 73 and others have found that recovery may be perfect after 
a primary suture, but that it is not so good following secondary 
operations, as sensory recovery is rarely perfect. Borchard, 6 on 
the other hand, claims that operation for secondary injuries results 



MAC AUSLAND, MAC AUSLAND I THE MUSCULOSPIRAL NERVE 9 

more favorably because in primary suture any neglect of aseptic 
requirements is followed by failure of nerve suture. 

Although the prognosis is better if the interval between the 
injury and operation is short, still there is a chance of complete 
recovery after a long period of paralysis. Cases operated after 
sixteen months or even after three and a half years following fracture 
have resulted in complete restoration of function. 

The establishment of continuity by end-to-end suture offers 
a greater chance of success than any other operative procedures 
such as grafting, implantation, or transplantation of nerve. 

Indications for Exploration. Any open wound over the musculo- 
spiral nerve accompanied by wrist-drop, should be enlarged and the 
nerve examined. If a division of the nerve is present, a suture 
should be done at once. 

If the nerve is injured from a blow in which it seems probable that 
complete division has taken place, suturing should be done early. 
Sometimes, however, the bruised condition of the soft parts is such 
that it is necessary to postpone a needed operation until the hemor- 
rhage is reabsorbed, and a favorable opportunity offered for the 
healing of the wound. If the exact condition of the nerve cannot 
be determined, it is well to wait to see if power returns spontaneously. 
During this period, however, the fingers and wrist should be held 
in hyperextension, which position always favors the return of muscle 
power. 

In the presence of fractures accompanied by radial paralysis 
in which it is impossible to determine whether paralysis is due to 
contusion or sectioning, it is best to first obtain reduction of the 
fracture and apply plaster. The muscles should then be watched 
for signs of atrophy and the fingers and the thumb should be exer- 
cised daily. If, after three or four months, paralysis still persists, 
exporatory operation should be performed. 

Operative Technic. The method of treating the nerve must 
vary according to the pathological findings. If the nerve is found 
intact, often only a simple operation, such as removing the bone 
over which the nerve is stretched, or removing scar tissue or exces- 
sive callus, may be necessary to give relief. 

Frequently, however, the nerve may be completely divided, 
constricted, torn, or bulbous at one end. In such cases, the usual 
procedure is to excise the affected portion, freshen the nerve ends, 
and establish continuity by suture. Nerve sutures have given very 
gratifying results and are recommended by many operators, 
including McCurdy, 48 Keen, 42 Cheyne, 13 Eve, 22 Ashhurst, 1 Auvray, 2 
and many others. 

Author's Technic. The approach to the part of the nerve 
involved is most successful if the upper and lower parts outside 
the field of injury are located and a dissection made up and down to 



10 MAC AUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 

the seat of damage. This approach is not only much safer but 
quicker than other method. When the ends of the nerve are found 
bulbous, or a distinct swelling or constriction is felt in the nerve 
trunk, it is best to cut out this section by means of a safety-razor 
blade. The ends are then approximated and the entire sheath 
about the nerve sutured with linen. In cases of division of the 
nerve in which retraction has taken place it is often necessary to 
place the arm in flexion to gain approximation. It is rarely neces- 
sary to shorten the humerus. 

After the ends have been sutured, the nerve should be placed in 
a new non-scar tissue bed, usually between layers of fat or muscle. 
There is some discussion as to whether fat is the best substance to 
prevent the formation of adhesions. Henle, 35 Morris 50 Williams, 81 
and many others approve its use. Other operators believe that the 
fat atrophies, and they recommend the method used by Fessler 24 
and Grisson, 31 of wrapping the nerve in a muscle flap of the triceps or 
of the brachialis. 

The elbow should be held in flexion for at least five to six weeks, 
and then gentle passive motions may be started. The wrist and 
fingers must be held in hyperextension to avoid flexion contraction, 
to favor muscle regeneration, and to prevent the stretching of the 
extensors which, in itself is an important factor in hindering the 
return of muscle power. 

As soon as motion begins to return, graduated massage and muscle 
training are of great advantage. The time when improvement 
begins varies from a week to several months. Motion usually 
begins to return in three or four months and it is usually a year 
before restoration is complete. 

It may happen that after excision of the affected portion of the 
nerve, too large a gap exists to allow the approximation of the nerve 
ends. Such a condition is not frequently found in civil life, but 
war injuries often destroy a large part of the nerve. Several means 
have been used to bridge the space. 

Piper, 60 Morton, 51 and Sherren 73 advised the manual stretching 
of the nerve and suture after the ends were in apposition. 

Plastic neurotomy was used with success by Harrison 33 who 
turned into the space a flap from the upper end of the nerve which 
was bulbous. Dawbarn and Byrne 15 bridged a 3-inch gap by 
splitting the nerve at a low point of its distal portion and swinging 
the long shaft thus made into the space. Sherren 73 believed a flap 
should be used as rarely as possible, because such an operation 
necessarily is technically complicated. 

Implantation of nerve, the method of attaching the stump of 
the distal end of the severed nerve to a healthy nerve, was first 
proposed by Lobker. 46 Roques de Fursac 70 implanted the musculo- 
spiral nerve in the median. Barkley 3 anastomosed the proximal 



MACATJSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 11 

and distal ends with the median. Auvray 2 formed an anastomosis 
of the lower end of the radial with the internal brachialis cutaneous 
nerve. These procedures are of little value if the fibers of the healthy 
nerve are not separated and such an operation is difficult. 

A few successful results from nerve grafting have been reported. 
Auvray 2 transplanted successfully a portion of the internal brachialis 
nerve 10 to 12 cm. long between the two freshened extremities of 
the musculospiral nerve. Sherren 73 suggested using for grafts 
the internal saphenous nerve obtained from the patient or from a 
recently amputated limb. Neuhof, 87 in a recent article on the trans- 
plantation of nerves in general, stated that as yet it was impossible 
to estimate the value of nerve transplantation. Only a few success- 
ful results have been obtained and the cases in literature have 
been recorded too early to judge the final result. 

Still other means of bridging the gap have been suggested. 
A tubular suture has been proposed by some surgeons. Sherren 73 
preferred a tube composed of one of the patient's superficial veins. 
Foreign materials have also been used. Keen 42 applied catgut 
threads, and Morris 50 bridged a gap of 3 cm. with silk thread. 
Magnesium was tried, but it was found to harden. Reisinger 68 
proposed sinking the nerve in the triceps muscle and fixing it there. 

Resection of the humerus as a means of allowing the approxima- 
tion of the nerve ends is justifiable only in cases of ununited frac- 
tures complicated by division of the nerve. Oilier 59 has reported 
early cases of resection. Keen 42 reported using this method in 
1 case and Riethus 69 in 3 cases. 

If the damage to the musculospiral nerve is irreparable by the 
use of any of the methods mentioned, or if a case has not been 
relieved by end-to-end suture, then tendon transplantation is a com- 
mendable procedure. Its object is the improvement and restoration 
of muscle balance in the hand. 

As the extensors of the wrist and fingers have lost their power, 
the problem is to transpose some of the muscles on the flexor aspect 
of the forearm without interfering with the power of flexion. The 
flexor carpi radialis, the flexor carpi ulnaris, and the pronator radii 
may be relied upon for this procedure. 

Author's Technic. The attachment of the flexor carpi radialis 
is severed through a 1-inch incision made directly over it on the 
anterior surface of the wrist. A second incision is made half way 
up the forearm along the course of the flexor carpi radialis tendon, 
and the tendon pulled up. A long L-shaped incision is made across 
the back of the wrist and up the side of the ulna. The flap is 
dissected upward, the tendon of the flexor carpi radialis is thrust 
obliquely over the edge of the radius and made to appear over the 
back of the lower end of the radius. (Fig. 3) . The ulnar tendon is 
severed at its attachment, carefully dissected upward as far as the 



12 MAC AUSLAJSTD, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

incision permits, and the whole muscle turned over, so that the 
tendon lies along the back of the lower end of the ulna. 

During the completion of the operation the wrist and fingers 
are held in hyperextension. All the extensors are split to receive 




Fig. 3. — Showing incisions over attachment of flexor radialis and along the course of 
the tendon. The tendon is thrust obliquely over the edge of the radius. 

these tendons, which are crossed through them (Fig. 4.). The 
thumb extensors are also included in those cases in which special 
provision has not been made for the extension of the thumb by the 
use of the pronator radii teres or the palmaris longus. 




Fig. 4. — Showing the L-shaped incision across the back of wrist and up the side- 
of ulna. The ulnar tendon has been severed at its attachment and the whole muscle 
turned over. The radial and ulnar tendons are seen running through the extensors- 
which are slit to receive them. 



The wound is closed. A splint is applied with the wrist and 
fingers held in hyperextension. This is worn for six to eight weeks 
during which time massage and passive motion are carried out. 



MACAUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 13 

Case IV. F. A., was ill in 1916 with acute arthritis of the 
shoulder. After an operation in which some dead bone was removed, 
wrist-drop and loss of elbow motion were noticed. 







.._ 


1 1 


"Hfc^ 





Fig. 5.— Case IV. F. A. 



Showing wristdrop and hand deformity before tendon 
transplantation . 



January, 1917. The patient was seen for the first time. Radio- 
grams showed a diffuse osteomyelitic process involving the whole 
humerus. The shaft was opened in toto and four days later the 
patient was able to extend the fingers, showing some power in the 
radial nerve. 




Fig. 6. — Case IV. F. A. Hand in splint after tendon transplantation. 



September, 1917. The patient discarded the leather brace he 
had been wearing and a small hyperextension hand splint was 
applied. A radiogram later showed complete regeneration of the 
humerus. Daily olive oil massage and constant use of the hand 
were advised. 



14 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

November 5, 1919. The power of extension of the wrist had not 
been regained (Fig. 5). A tendon transplantation was performed 
according to the above technic. 

November 29, 1919. Massage and muscle training were started. 

December 8, 1919. The patient was able to hyperextend the 
wrist. 

September 8, 1920. He had voluntary extension of the wrist 
to within 15° of normal, and voluntary extension of the fingers to 
within 20° to 40° of normal. The extension of the thumb was 
deficient, but satisfactory (Fig. 6). 




Fig. 7— Case IV. F. A. 



Voluntary extension four years after tendon 
transplantation. 



Case V. M., admitted to the Alder Hey Hospital September 26, 
1917, had suffered a compound fracture of the right humerus and 
severance of the musculospiral on May 9, 1915. 

History. He had been treated in France, having had 7 opera- 
tions for removal of shrapnel and cleaning of wound. The last 
operation was supposed to have been on the nerve. 

Examination. The wound had been healed eight months. The 
present complaint was wrist-drop. Two long scars were attached 
to the bone in the upper arm. The humerus was shortened and 
irregularly thickened in middle and lower thirds. There was no 
power in the extensors of forearm. There was slight sensory loss 
over first phalanx of thumb. From the depth of the density of the 
scars, a wide gap of nerve seemed probable. 

Electrical Reactions. The median and ulnar sensations were not 
affected. The radial sensation, E. and P. was impaired on the 
whole dorsal surface of the thumb, and slightly over the knuckle 
of the index finger. The forearm sensation was not affected over 
the musculospiral area. The extensors of the thumb, F.a., G. 



MAC AUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 15 

faint, K. C. C.) A. C. C. Ext. communis, F.a., G. fair K. C. C.) 
A. C. C. The ulnar and median muscles were normal. 

Diagnosis. The musculospiral nerve was involved in callus. 

Treatment. On October 9, 1917 an operation was performed 
by Dr. A. R. MacAusland. Through a 5-inch incision, the musculo- 
spiral nerve was exposed just above the elbow, and followed up 
about an inch into very dense scar, where its course could not be 
traced farther. Without disturbing this region to any extent, 
the nerve was exposed on the axillary side as it entered the musculo- 
spiral groove, where it was found to be free for a short distance. 
It then entered dense scar tissue, but was carefully traced for 
about 1 inch more to the region of the very deep posterior scar. 
The dissection was completed through the incision on the outer 
side of the arm. The nerve ran into scar with only slight tendency 
to bulb. Exploration of scar farther revealed no nerve elements. 
The gap of about 3 inches was filled in with a section of the cutaneous 
nerve from the inner side of the musculospiral nerve in the axilla. 
It was not possible to bring the nerve ends together with graft, 
even by the expedient of crossing it in front of the humerus. 

October 12, 1917. No pain, no temperature. 

October 23, 1917. Clean; healed. Tendon transplantation 
seemed advisable. 

November 13, 1917. Operation: Tendon transplantation. 
Flexor V. rad. into extensors of thumb, extensors longior and 
brevior and other extensors. 

November 14, 1917. The patient had considerable pain. The 
circulation was good. 

November 19, 1917. The patient was much more comfortable. 
He was advised to wear a long cock-up splint, with strap and thumb 
piece. 

November 23, 1917. The thumb was to be extended. The 
wound showed slight sepsis. 

November 26, 1917. The wound was clean. A short cock-up 
splint was to be applied. 

Transplantation of the tendons for musculospiral nerve paralysis 
has been a most successful operation, as the tendons used are 
-constant and strong. The early attempts to convert tendons into 
ligaments were made by Tilanus, 75 Codivilla, 14 Reiner, 67 and Gallic 26 
Jones, 39 Francke, 25 Muller-Aachen, 54 Vulpius, 80 Drobnik, 19 and 
Murphy 55 advocated this procedure in cases of extensive destruction 
of the nerve. 

Jones 39 has outlined a tendon transplantation operation in which 
he converts the three extensors into ligaments so that the carpus 
can be fixed in the best functional attitude of dorsiflexion and still 
permit movement at the wrist- joint, but not in the direction of the 
deformity. 



16 MACAUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 

His operative technic consists of making a 3^-inch incision from 
just above the back of the wrist-joint extending up the middle of 
the forearm. By retracting the extensor ossis metacarpi pollicis 
and the extensor brevis pollicis, the two radial extensors may be 
followed along the forearm and divided high up and the ends pulled 
down. A tunnel is then drilled across the radius from the outer 
side, a little over an inch above the line of the wrist-joint. After 
the tendons have been scarified the extensor carpi radialis longior 
is pulled through the tunnel from the outer side and the brevior 
from the inner side. Their ends overlap and are sewed with a 
continuous catgut suture. In the same way the extensor carpi 
ulnaris is followed up to the forearm, divided, and the ends drawn 
through a tunnel in the ulna. Any tendency toward radial deviation 
of the hand by the pull of the radial extensor is thus corrected. The 
hand and forearm are encased in plaster. It is important to support 
the hand in the dorsiflexed position from the time the first catgut 
suture is inserted until the last plaster bandage is applied. In 
two or three months the patient may use his hand. 

In a case of complete paralysis of the nerve Miiller 54 tried tendon 
transplantation by cutting the tendon of the flexor carpi ulnaris 
and uniting it with the extensor tendons of the fingers. Seven 
months later the tendon of the flexor carpi radialis longus was cut 
and sutured to the tendon of the abductor of the thumb and the 
extensor carpi radialis longus. The patient was then capable of 
lifting the hand to a horizontal position and of abducting the thumb. 

Murphy 56 released the flexor carpi radialis dorsally for 4 inches by 
tunneling through a button-hole incision. It was passed subcuta- 
neously downward to the upper margin of the posterior annular 
ligament. The extensor tendons of the thumb and of each finger 
(two for the index and two for the little finger) were transfixed. 
The tendon of the thumb and of the index finger were attached 
obliquely from above downward and inward so that extension would 
not bring the inner three fingers into play ahead of the thumb and 
index finger. 

Vulpius 80 reported 28 cases of tendon transplantation and Drob- 
nik 19 reported 16 cases. 

Sir Robert Jones 40 makes use of the pronator radii teres to produce 
extension of the wrist, by inserting it into the two radial extensors, 
and the flexor carpi radialis and the flexor carpi ulnaris to produce 
extension of the fingers and thumb by insertion into these tendons. 
During the whole procedure of tendon suture he keeps the wrist 
and fingers in complete dorsiflexion and the thumb in full abduction 
in order to procure the best action from the transplanted tendons. 
After operation the limb is placed in a splint which keeps the wrist 
in full dorsiflexion and the metacarpophalangeal and the interpha- 
langeal joints flexed at an angle of about 10°. 

Jones has used this technic in 20 cases. All the patients were 



MAC AUSLAND, MACAUSLAND: THE MUSCTJLOSPIRAL NERVE 17 

able to dorsiflex the wrist with the fingers closed and then to extend 
the fingers while the wrist remained in dorsiflexion. 

Pathology. In operating for musculospiral nerve paralysis, the 
nerve is often found intact, but stretching over bony fragments or 
involvement in scar tissue or callus prevents it from having normal 
power. 

If the nerve is crushed or torn the changes differ from those which 
occur as the result of severing by a sharp knife. In the latter case 
there is no contact between the two ends of the nerve and the changes 
differ in the proximal and distal parts. The proximal end becomes 
markedly bulbous. The distal end becomes shrunken, tapering, 
or slightly bulbous. 

If the nerve is crushed it becomes inflamed and the inflammatory 
condition may lead to complete destruction. The nerve sheath 
may not be damaged, but the nerve fibers being inflamed, a con- 
striction or a bulbous formation may develop within the sheath. 

Reparative Processes. The regenerative process depends upon 
the trauma, the pathology and nourishment of the nerve. 

Henriksen 36 made experimental investigations to determine the 
exact regenerative processes in a nerve that was completely divided 
and in one damaged in a crushing injury. He found that after 
complete division regeneration begins immediately, developing most 
rapidly in the central stump where fully organized myelin fibers 
may exist as early as ten days after injury. The first histological 
sign of regeneration is activity of the neurilemma nuclei which begin 
to proliferate. The protoplasm at the poles of the nuclei increases 
and grows into thin threads through the old Schwann sheaths and 
out into the severed nerve ends forming a bridge between the latter. 
Henriksen found that in the course of a few days these threads 
may bridge a gap of more than 0.5 cm., and that the old Schwann 
sheaths are pierced by long protoplasmic threads before the old 
threads have completely lost their structure. Fully characteristic 
nerve segments may be found in the central stump ten days after 
severance. 

When a nerve is severed, its muscle loses weight and degenerative 
changes occur. At the same time the sarcolemma nuclei become 
active and new cellular matter forms in the muscle. When innerva- 
tion begins, these cells form the basis for the formation of young 
muscular fibers. It is difficult to tell just when the muscle regains 
tone, but it may be late, five to six weeks after a primary suture. 

Henriksen, in experimenting on rabbits, could find no essential 
difference in the process of regeneration when the nerve was sutured 
or when it healed unaided. In fact, the nerve fibers were at first 
found deflected as a result of the pull of the thread, although later 
they straightened out. Nerve suture, however, is necessary when 
obstacles prevent spontaneous healing. 

One would naturally assume that a crushed nerve would regenerate 



18 MACAUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

more easily and quickly than a severed nerve, but clinical examina- 
tions show that physiological restitution is often not so complete 
and is often slower in a case of a crushed nerve. The nourishment 
may be established more rapidly, but disturbances may appear 
in the process of regeneration, or the myelin differentiation may be 
disturbed, thus hindering the healing. After a complete severance 
of the nerve, the mass growing out from the ends to form the bridge 
between the ends thickens, and the nerve recovers its smooth appear- 
ance. If the nerve is crushed the thickness is uneven and it infil- 
trates the surrounding tissues. The peripheric part of the nerve 
is swollen and edematous. 

Literature. After von Busch 10 and Oilier 59 in 1865 reported good 
success in operating in cases of paralysis following fractures of the 
humerus, many similar cases were recorded in literature. In 1886, 
von Bruns 9 reported 189 cases of nerve injuries. Seventy-three of 
the 138 cases of the upper extremities were musculospiral nerve 
paralysis following fractures of the humerus. 

In 1889 Bowlby 7 issued statistics of the operated cases that had 
been published. All the cases, 2 by Trelat, 77 2 by Bidder, 1 each 
by Erickson, Oilier, Whitson, Delans, Israel, 38 Tillaux, 76 and Hueke 
had resulted from fractures of the humerus and were due to stretch- 
ing, contusion or pressure. The results in 7 of these cases were 
satisfactory. 

Goldstein 29 in 1892, Wolfler 83 in 1895, Neugebauer, 56 Zoege- 
Manteuffel, 84 and Drewitz 18 in 1895, reported several cases in which 
the nerve was found compressed in scar masses or bony callus. 
Successful results were obtained by operative interference. 

In 1899 Riethus 69 described fully 7 of his cases. In 5 cases the 
nerve was compressed by bony callus or fibrous tissue. Complete 
cures were effected by operative interference in 2 of the cases and 
essential improvement was obtained in 2 cases. The result in the 
fifth case was not reported. Excellent results were obtained in 
2 other cases in 1 of which the nerve was stabbed on the edge of a 
fragment of bone, and in the other in which the nerve was stretched 
over a sharp bony edge. 

The same year Willmers 82 reported a successful result. 

In 1900, Keen 42 reported a series of 7 cases, in 6 of which opera- 
tions were performed for paralysis of the musculospiral nerve fol- 
lowing fracture of the humerus. Complete restoration of function 
was secured in 2 cases by suture of the nerve. A useful arm was 
obtained in 1 case in which the humerus was resected to approxi- 
mate the ends of the nerve over a gap of 5 cm. As the other 
patients did not carry out the postoperative requirements, very little 
improvement took place in 2 cases and no improvement in 1 case. 

In 1 case of complete division of the nerve by a knife blade, Keen 
sutured the nerve ends with silk thread. Fourteen months later 
the patient had a good, useful hand. 



MACAUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 19 

Launois and Lejars 44 reported a successful case in paralysis 
following a fracture. 

Braiininger, 8 Kramer, 43 and Reisinger 68 also reported good results 
in freeing the nerve from compression. 

In 1905, Piper 60 published his monograph on the subject of 
musculospiral nerve paralysis following fractures of the humerus. 
After reviewing the literature from early times and describing the 
various types of operative technic, he cited 4 cases from the Kieler 
Clinic. One case was not operated. The second in which the nerve 
was pleated and a layer of the triceps laid between it and the bone, 
resulted in a weak hand. In the third case the nerve was found 
intact, but twisted above the seat of fracture ; paralysis was overcome 
by freeing the nerve. In the fourth case the nerve was intact but 
involved in callus. The definite outcome of the operation was not 
recorded, but the latest record was the beginning of a degenerative 
reaction. 

Scudder and Paul 71 reported 11 cases of suture in the Massachu- 
setts General Hospital. Eight cases were relieved by operation. 
The other 3 cases were failures. 

Of 12 cases reported by Borchard 6 in 1907, 2 were unsuited for 
operative handling; in 2 cases the nerve was sutured; in 3 cases it 
was simply loosened from adhesions; in 3 cases bony masses and 
scar tissue were removed; in 1 case it was necessary to excise 
the radial head, and in the twelfth case nerve grafting was employed 
to bridge a large defect. Except in the last 2 cases on which it 
was too early to report, the condition was cured by operation. 

In 1909, Harrison 33 reported 2 cases, 1 in which the nerve was 
compressed by callus and 1 in which the nerve crossed in front of 
the humerus. Operation on the first case in which a flap of the nerve 
was turned in to bridge a wide gap, resulted in a good serviceable 
hand. In the second case it was necessary to divide the humerus 
in order to place the nerve in position. In three and a half 
months the patient could extend his hand to an angle of 150° with 
the forearm, and further improvement was expected. 

Els 21 reported 2 cases of secondary suture. Perfect function 
resulted in the first case from operation for partial tearing of the 
nerve over a bony fragment. The result in the second case of 
paralysis due to the involvement of the nerve in scar tissue, was good, 
but the hand was somewhat weak. 

Charbonnel 12 reported a case of double fracture and splintering 
of the humerus followed by nerve paralysis. The nerve was freed 
from between the long supinatus and the anterior brachialis, and 
in six and a half months the patient had normal movements. 

Barkley 3 reported a case in which the humerus was broken in 
two places, and there was a loss of 4 inches of substance of the nerve. 
The ends were anastomosed with the median nerve, and complete 
use of the hand resulted. 



20 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

In 1911, Morestin 49 reported 3 cases on which he had operated. 
In 1 following fracture of the humerus, the nerve was freed from 
between the fragments and sutured, and in one month there were 
good prospects for success. In the second and third cases of 
paralysis, likewise following fractures, the nerves were found embed- 
ded in callus. Fifteen days after operation in the second case, the 
patient could extend the hand and fingers almost to normal. Opera- 
tion on the third case also resulted in the return of all normal 
movements. 

Schwartz 72 operated for a case of paralysis following fracture of 
the humerus. He freed the nerve from callus and interposed a 
layer of muscular and fibrous tissue between it and the bone. In 
ten months recovery was complete. 

Gaudier and Deladriere 28 reported a case of paralysis following 
fracture of the humerus. Five months after the nerve was freed 
from adhesions the patient had recovered all movements. 

In 1912, Nikoloff 58 cited a case in which the paralysis appeared 
three weeks after the healing of a fracture of the humerus. To 
bridge the gap, a tube of fibrous cord was made and the non- 
paralyzed end of the nerve sutured to the paralyzed end. A muscle 
layer was inserted to separate the nerve from the bone. A complete 
return of movement was obtained. 

Judet 41 cited a case of secondary paralysis following fracture of 
the humerus in which the nerve was found compressed by a spicule 
of bone. Operation resulted in a complete cure. 

Ferraton 23 sutured a nerve that had been destroyed in a com- 
minuted fracture of the humerus caused by a bullet. All movements 
of the hand returned. 

Murphy 55 reported establishing end-to-end union of the nerve 
by applying a flap. In another case he united the ends of the 
nerve at the central septum to the triceps muscle. He did not 
report his results. 

Gallois and Tartanson 27 reported 2 successful cases in which 
paralysis had followed fractures. After isolation of the nerve 
from the callus, a layer of muscle was inserted between it and the 
bone to prevent further complications. 

In 1914, Mosti 52 cited a case of secondary suture that resulted 
in complete success. Quenu 64 also reported a successful case of 
secondary suture. Hohmann 37 operated on 1 case of paralysis 
following fracture of the humerus. 

In 1916, Dawbarn and Byrne 16 did a splitting neuroplastic opera- 
tion in a case of destruction of the nerve from a fracture of the 
humerus. An irregular form of regeneration resulted. 

Successful results from suturing of the nerves were reported by 
Souques, 74 Loewenstein 47 and Ranschborg. 65 Moszkowski 53 pre- 
sented a case in which a pedicled flap of the triceps muscle was 
used to bridge the defect in the nerve. At the time of his report 



MACAUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 21 

it was too early for complete restoration but signs of regenera- 
tion were apparent. Two successful nerve suture operations for 
complete division of the nerve were presented by McCurdy 48 
in 1917. 

Beck 4 operated for a paralysis resulting from a fracture that had 
occurred seven months before. In operation a tubule of fascia 
lata and fat was transplanted into the extensor tendons. Twelve 
weeks after the operation, considerable power had returned to the 
muscles. 

Morris 50 reported a successful case of secondary suture for paraly- 
sis following non-union of a fracture of the humerus. In discussion 
of his report, Green and Hitzrob reported similar cases in which they 
had been successful. 

Hartwell 34 reported a case of a successful suture forty-six days 
after section of the nerve by a stab wound. 

Due to the frequency of injury to the musculospiral nerve in 
war wounds, there were many operations performed between the 
years 1917 and 1921. Gosset, 30 in 1923, summed up very well 
the results of these operations. 

In 1917, Gosset, 30 himself, reported 144 cases. In 44 cases of 
freeing of the nerve, there were 26 successful results, 10 cases of 
improvement, and 8 failures. In 27 cases of suture for complete 
sectioning, there were 16 good results, 1 case of improvement, and 
10 failures. In 2 cases of suture for incomplete sectioning, there 
was 1 cure and 1 failure. 

In 1918, Gosset and his pupil Charrier studied 76 cases. In 
18 cases in which the nerve was freed from compression, 95 per cent 
recoveries were obtained. The condition of the other patients was 
improved. Thirteen cases of complete sectioning in which the 
nerve was sutured, resulted in 4 recoveries and 3 failures due to 
bad technic. The condition of the other 6 patients was slightly 
improved. In 21 cases of incomplete sectioning, there was a 
fibrous formation between the nerve ends which some operators 
believed might be used as a means of conductivity. In the 5 cases 
in which this tissue was utilized there were 4 failures. In the 
other cases the fibrous formations were excised and an end-to-end 
suture was done. There were 9 good results, 4 cases of improve- 
ment, and 3 failures. These results show clearly that the fibrous 
formations do not act as conductors of nerve influence. 

Dumas 20 reported the results of 115 cases that were operated upon. 
In 18 cases of freeing the nerves from compression, 83 per cent good 
results, and 11 per cent fair results were obtained; in 41 cases of 
incomplete severance 70 per cent successful results and 11 per cent 
fair results; in 46 cases of sectioning with some fibrous continuity 
remaining, 43 per cent successful results, 10 per cent fair results 
and 46 per cent failures; in 10 cases of complete severance treated 
by suturing, 1 fair result. The other cases were failures. 



22 MAC AUSLAND, MAC AUSLAND : THE MUSCULOSPIRAL NERVE 

In 1918, Delageniere and Tinel 17 reported 181 sutures with 88 
per cent positive results. Villard 79 reported 8 suture operations 
with 4 good results. 

Reder 66 reported a case of complete paralysis caused by a shot 
wound. At operation a strip of muscle taken from the head of the 
triceps was wound around the point of injury. In forty weeks all 
movements, except the ability to pick up a pin, were possible. 

Auvray 2 in 1919, collected the results of 31 cases of wounds of 
the nerve operated in 1915. Of 15 cases of simple freeing of the 
nerve from compression, 7 patients obtained complete restoration 
of function; 4 an improved condition, and there was 1 failure; of 
11 cases of end-to-end suture, 8 patients obtained complete restora- 
tion and there were 3 failures; 1 case of excision of a cicatricial 
nodule from the middle of the nerve was successful; and 1 case of 
nerve graft 10 to 12 cm. long from the internal brachialis cutaneous 
nerve resulted successfully. Three cases of anastomosis and re- 
doubling of the upper end of the nerve were failures. On the average 
Auvray found amelioration had begun at the end of several months, 
usually four to eight. 

In discussion of Auvray's report Wiart cited statistics less satis- 
fying. Of 25 sutures, there were only 5 complete cures, and 5 
cases of improvement; of 61 cases of freeing the nerve there were 20 
complete cures, and 20 ameliorations. 

In 11 cases of suture, Cestan 11 obtained 5 complete cures. The 
condition of 4 other patients was improved by operation. Two cases 
were failures. 

Putzu 62 obtained 85 per cent cures in operations of freeing the 
nerve and 47 per cent cures in suture operations. Dane 15 secured 
50 per cent good results. Piatt 61 collected 35 cases of nerve suturing 
in which 26 very good results were obtained. 

From the results of the above cases it is seen that operations of 
freeing the nerve give 95 per cent good results and suture operations 
give 45 to 55 per cent. 

Henriksen, 36 in 1923, reported 5 successful cases in 2 of which the 
nerve was sutured, in 1 4 cm. of the humerus was resected to 
bridge a gap of 6 cm., and in 2 cases the nerve was freed from callus. 

Conclusions. 1. The nerve may be injured in three ways: The 
nerve trunk may be crushed without damage to the sheath ; the nerve 
may be completely divided ; power may be lost through the involve- 
ment of the nerve in scar tissue or callus. 

2. Early recognition and treatment of nerve injuries in connection 
with fractures and severe traumatisms is very important. We 
may expect a perfect result in cases of immediate suture of the nerve. 
While intervention in cases of old standing has given good results, 
it is the general opinion that the chances of success are lessened 
after the elapse of a long period of paralysis. 



MACAUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 23 

3. Simple freeing of the nerve is very often the only procedure 
necessary to relieve the condition. In cases of complete division 
of the nerve or in cases in which there is need to excise a portion of 
it because of a fibrous formation, nerve suture has been found the 
most satisfactory procedure for the approximation of the nerve 
ends. If the nerve suture does not relieve the condition, or if the 
case is not reparable by the various methods of manual stretching, 
neurotomy or nerve grafting, then tendon transplantation gives 
satisfactory results. 

4. After severance of a nerve, healing begins spontaneously. 
In cases of nerve suture function develops in the same manner as 
in spontaneous healing. After secondary suture sensibility returns 
early. Muscle control usually appears in the course of two to 
four months and is complete in from six to nine months, depending 
upon the location of the nerve injury. 



BIBLIOGRAPHY. 

1. Ashhurst: Trs. Phila. Acad. Surg., 1911, 13, 30. 

2. Auvray: Bull. et. mem. Soc. de chir., 1919, 45, 1291. 

3. Barkley: Lancet-Clinic, 1910, 104, 508. 

4. Beck: Surg. Clin., Chicago, 1918, 2, 406. 

5. Blenk: Monatschr. f. Unfallheilk., 1903, 10, 1. 

6. Borchard: Deutsch. Ztschr. f. Chir., 1907, 87, 1. 

7. Bowlby: Injuries and Diseases of Nerves, 1889. 

8. Braiininger: Miinchen med. Wchnschr., 1900, 47, 290. 

9. von Bruns: Neurol. Centralbl., 1902, 21, 1042. 

10. von Busch: Sitzungsb. d. nied.-rhein. Gesellsch. f. Nat.-u. Heilk. zu. Bonn, 
1862-3, p. 155. 

11. Cestan: Rev. neurolog., 1918, 25, 148. 

12. Charbonnel: Jour, de med. de Bordeaux, 1910, 40, 499. 

13. Cheyne: Manual of Surg., 1900, 2, 382. 

14. Codivilla: Arch, di ortopl, 1899, 16, 225. 

15. Dane: Brit. Med. Jour., 1921, 2, 885. 

16. Dawbarn and Byrne: New York Med. Jour., 1915, 102, 730. 

17. Delageniere and Tinel: Bull et mem. Soc. de chir., 1918, 44, 524. 

18. Drewitz: Monatschr. f. Unfallheilk., 1896, 3, 8. 

19. Drobnik: Reported by Piper. 

20. Dumas: Bull, et mem. Soc. de chir., 1917, 43, 1184. 

21. Els: Beitr. z. klin. Chir., 1910, 68, 394. 

22. Eve: South. Pract., 1907, 29, 306. 

23. Ferraton: Bull, et mem. Soc. de chir., 1912, 38, 299. 

24. Fessler: Deutsch. Ztschr. f. Chir., 1905, 78, 60. 

25. Franke: Arch. f. klin. Chir., 1898, 67, 763; Berl. klin. Wchnschr., 1899, 36, 
244. 

26. Gallie: Ann. Surg., 1915, 62, 481. 

27. Gallois and Tartanson: Lyon med., 1912, 118, 757. 

28. Gaudier and Deladriere: Echo med. du nord, 1911, 15, 25. 

29. Goldstein: Deutsch. Ztschr. f. Chir., 1895, 40, 566. 

30. Gosset: a. Resultats obtenus dans la chirurgie des blessures des nerfs periph- 
eriques par projectiles de guerre (presented before the International Congress of 
Surgery, London, July 18, 1923; Arch. med. et phar. miliatir., 1917-1920, 68-72. 

31. Grisson: Deutsch. med. Wchnschr., 1904, 30, 901. 

32. Hamilton: Arch. Neurol. Psych., 1920, 3, 277. 

33. Harrison: Practitioner, 1909, 83, 698. 



24 MACAUSLAND, MACAUSLAND: THE MUSCULOSPIRAL NERVE 

34. Hartwell: Surg. Clin. North America, 1921, 1, 399; Ann. Surg., 1921, 73, 665. 

35. Henle: Arch. f. klin. Chir., 1906, 79, 1044. 

36. Henriksen: The Results of Surgical Treatment of Injury of the Nerves 
(Presented before the International Congress of Surgery, London, July 18, 1923). 

37. Hohmann: Miinchen med. Wchnschr., 1914, 61, 2352. 

38. Israel: Gaz. hebd. de med., 1884, 21, 281. 

39. Jones: Jour. Orthop. Surg., 1919, 1, 135. 

40. Jones: Orthorp. Surg., London, 1921. 

41. Judet: Paris chirurg., 1912, 4, 292. 

42. Keen: Med. Chron., Manchester, 1900, 3, 337. 

43. Kramer: Beitr. z. klin. Chir., 1900, 28, 423. 

44. Launois and Lejars: Rev. de chir., 1903, 27, 574. 

45. Letievant: Traite des sections nerveuses, Paris, 1873. 

46. Lobker: Centralbl f. Chir., 1884, 2, 841. 

47. Lowenstein. Miinchen. med. Wchnschr., 1916, 63, 1405. 

48. McCurdy: Am. Jour. Orthop. Surg., 1917, 15, 711. 

49. Morestin: Bull, et mem. Soc. de chir., 1911, 37, 1179. 

50. Morris: Ann. Surg., 1919, 69, 338. 

51. Morton: Lancet, 1918, 1, 373. 

52. Mosti: Policlin. (sez chir.), 1914, 21, 563. 

53. Moszkowski: Wien. klin. Wchnschr., 1916, 29, 725. 

54. Milller: Ztschr. f. klin. Med., 1899, 38, 433. 

55. Murphy: Surg. Clin., Chicago, 1912, 1, 91. 

56. Neugebauer: Beitr. z. klin. Chir., 1896, 15, 465. 

57. Neuhof : The Transplantation of Tissues, New York, 1923, p. 171. 

58. Nikoloff : Nord. med., 1911, 18, 203. 

59. Oilier: Gaz. hebd. de med. et de chir., 1865, 2, 515. 

60. Piper: Fraktura humeri mit Verletzung des Nervus radialis, Kiel, 1905. 

61. Piatt: Brit. Med. Jour., 1921, 1, 596. 

62. Putzu: Riforma med., 1919, 35, 906. 

63. Quain: Anatomy, Vol. 3, Part II, 303. 

64. Quenu: Bull, et mem. Soc de chir., 1915, 41, 215. 

65. Ranschburg: Deutsch. med. Wchnschr., 1916, 42, 1546. 

66. Reder: Trs. South. Surg. Assn., 1918-19, 21, 355; Ann. Surg., 1919, 70, 226. 

67. Reiner: Ztschr. f. orthopad. Chir., 1904, 13, 451. 

68. Reisinger: Beitr. z. klin. Chir., 1902, 36, 618. 

69. Riethus: Beitr. z. klin. Chir., 1899, 24, 703 

70. Roques de Fursac: Berlin klin. Wchnschr., 1900, 37, 853. 

71. Scudder and Paul: Ann. Surg., 1905, 1, 1118. 

72. Schwartz: Bull, et mem. Soc. de chir., 1911, 37, 1131. 

73. Sherren: Brit. Med. Jour., 1910, 1, 130; Injuries of Nerves and Their 
Treatment, New York, 1908, p. 310; Modern Treatment of Nervous and Mental 
Diseases, Philadelphia and New York, 1013, 2, 54. 

74. Souques: Rev. Neurolog., 1916, 19, 99. 

75. Tilanus: Nerderl. Tijdschr. v. Geneesk., 1898, 2, 925. 

76. Tillaux: Bull, et mem. Soc. de chir., 1862, 8, 836. 

77. Trelat: Bull, et mem. Soc. de chir., 1882, 8, 834. 

78. U. S. A. Manual of Neuro-Surgery. 

79. Villard: Lyon med., 1916, 125, 192. 

80. Vulpius: Reported by Piper. 

81. Williams: Brit. Jour. Surg., 1918-19, 6, 315. 

82. Willmers: Dissertation, Bonn, 1899. 

83. Woelfler: Prag. med. Wchnschr., 1895, 20, 530. 

84. Zoege-Manteuffel: St. Petersburger med. Wchnschr., 1896, 13, 9. 



Reprint from 
SURGERY, GYNECOLOGY AND OBSTETRICS 

September, IQ2I, pages 223-245 



MOBILIZATION OF THE ELBOW BY FREE FASCIA TRANSPLANTATION 

WITH REPORT OF THIRTY-ONE CASES 1 

By W. RUSSELL MacAUSLAND, M.D., Boston 

Surgeon-in-Chief, Orthopedic Department, Carney Hospital 

IN a previous paper (38), read before the deposits in the joint, either of attenuated 
Orthopedic Section of the American bacteria or of toxins. The primary focus is 
Medical Association on June 23, 1914, I often difficult to locate. The ankylosis results 
reported 4 cases in which I had gained mobility from adhesions both within and without the 
in ankylosed elbow-joints by means of arthro- joint and is, at least at first, fibrous, 
plasty. In 2 of these, I used the Murphy meth- In the problem of treatment of any anky- 
od interposing pedunculated flaps of fat and losis, the location of the joint has to be con- 
fascia; in 2, free flaps of fascia lata. At the sidered. In the elbow, conditions are different 
same time, I gave a resume of the literature on from those in any other of the large joints. In 
previous attempts at mobilization in this the lower extremity, stability is far more 
joint. I should now like to consider briefly the important than motion. Here, particularly 
contributions which have been made to date at the knee, a firm, painless joint in good 
to the literature on this subject and also to position is far more useful than a wabbly one 
report my arthroplasties in full. continually subject to strains and wrenches. 

Ankylosis of the elbow results either from an In a shoulder ankylosed in an abducted 

infectious process or from traumatism. The position, a useful degree of motion may be 

latter is usually a fracture dislocation with had by the resulting hypermobility of the 

wide separation. The large amount of callus scapula. A stiff wrist in a good position, i.e., 

which forms as a result of this injury at first hyperextension, is serviceable; moreover, as 

interferes mechanically with motion; later, structures here are complicated, the joint does 

an ankylosis results, usually fibrous in not lend itself readily to arthroplasty. In the 

character. elbow, on the other hand, no position of 

The infectious process may be either acute ankylosis is favorable to function and any 

or chronic. In the former case, the causative position is ungainly. 

agent is usually the streptococcus, the Many methods have been tried to gain 

pneumococcus, or the gonococcus. The onset mobility in the elbow. Various nonabsorbable 

is sudden and the course severe, ending materials have been used. Gluck and others 

usually in a bony ankylosis. inserted ivory pegs; Pupovac, magnesium 

We may, on the other hand, have a slow, sheets, and other metals. Besides these, 

insidious, polyarthritic process. The focus of wood, celluloid, gutta percha, and temporary 

infection is situated elsewhere, and the joint packings of gauze have been used. Taylor (67) 

condition is caused by the haematogenous advocated a mixture of yellow wax and lanolin. 

•Read before the Southern Medical Association, November 15, ig2o. 

I 



SURGERY, GYNECOLOGY AND OBSTETRICS 



Widely varying organic substances have 
been tried. Rechet (57) covered the ends of the 
resected bones with periosteal flaps in various 
joints. Hofmann (32), in 1906, reported a case 
in which he transplanted periosteal flaps from 
the tibia to the resected end of the bones of 
the elbow. He obtained full extension and 
flexion to 80 degrees. 

Weglowski (74) reported a case in which he used 
successfully cartilage transplanted from the rib in an 
ankylosed elbow. 

Von Frisch (23) used periosteal grafts from the 
tibia in an elbow ankylosed from gonorrhceal 
arthritis. Only 25 degrees motion was obtained. 
The author attributed the result to lack of after- 
treatment. 

Herzberg (30) reported 4 cases in which trans- 
plantation of joints was done after resection. 
Ankylosis was the result of trauma. Three of the 
cases were children. 

Greiffenhagen (26) reported 3 cases in which 
periosteum was used in elbow-joints. 

Mauclair (39) used cartilage from the astragalus to 
cover the rough ends. X-ray later showed these 
fused to the bone. 

More recently, cartilage grafts were used by 
Delangeniere (16) after a resection had been done. 
The operation snowed no advantage over an ex- 
cision, as some instability of the joint followed. 
These methods have now been abandoned. 

Excision has a few advocates but, except for 
this, arthroplasty has succeeded all other 
methods. The first case reported is that of 
Verneriel (72) in i860. He gained motion 
by the use of a flap of muscle and fascia, 
interposed after resection of an ankylosed 
jaw. Helfereich's (28) report, however, in 
1893 brought the matter to more general 
attention. He also used a muscle flap for 
interposition. 

Albarran (1) reported a case in which ankylosis 
had followed operative reposition. A partial re- 
section was then done by which a good immediate 
result was obtained but later ankylosis again oc- 
curred. A third operation was undertaken which 
consisted of a resection of the olecranon and inter- 
position of a muscle fascia flap of the triceps. After 
two years, there was a range of motion from 65 to 1 1 5 
degrees. Extension was possible without the aid of 
gravity. Pronation and supination were normal. 
There was no lateral motion. 

Nelaton (45), in a case of ankylosis following a 
neisserian infection, resected an elbow and interposed 
a flap of the brachialis anticus. Two years after the 
operation, flexion and extension were normal, but 
pronation and supination were much decreased. 
Active extension required the weight of gravity. 



In 1903, Quenu (56, b) reported an arthroplasty of 
the elbow for an ankylosis following a severe trauma 
of the arm, consisting of a fracture of both bones of 
the forearm and destruction of the soft parts. After 
resection, he interposed a tendon fascia flap. There 
resulted flexion to a right angle and good but incom- 
plete extension. There was good pronation but 
difficulty in maintaining an intermediate position. 
The patient died a few months after the operation of 
pulmonary tuberculosis. 

Delbet (17) also reported mobilizing an elbow in a 
girl of six, which had become ankylosed in infancy, 
resulting in complete atrophy of the arm. At his 
first operation, he resected the joint without breaking 
up the ankylosis. Two months later after re- 
ankylosis, he intervened again, removing the bony 
spicules that had formed, o . 5 centimeter thick, 
from the humerus, the radius, and the ulna, and 
interposing some fibers of the flexor carpi ulnaris. 
Chloroform mobilization was necessary a month 
later but the final result was good, with flexion to a 
right angle and extension nearly complete. 

Berger (7), in the same year, mobilized a fibrous 
ankylosis by remodeling the bony parts and insert- 
ing a flap of the anconeus which he sutured to the 
brachialis anticus. He had not at the time of his 
report obtained active motion. 

Schanz (62), in 1904, reported a mobilization of a 
bony ankylosis following rheumatism. After chisel- 
ing through the joint, he enlarged the sigmoid fossa, 
removed a piece of the trochlea, and interposed a 
flap of fat from the under side of the forearm. Three 
months after the operation, the arm could be used 
for ordinary purposes. 

Murphy (43, a) first used his fascia method October, 
1901, on a knee-joint. A large layer of fascia lata 
with a thin layer of muscle tissue attached was 
dissected from the outer surface of the vastus 
externus, with its base below and anterior. A small 
flap of fascia covering the vastus internus was dis- 
sected free and placed between the patella and the 
femur. He first mobilized the elbow by this method 
in 1904 in a case of ankylosing arthritis. A pyriform 
flap of deep fascia was dissected from the posterior 
surface of the triceps. The flap was 4^2 inches long 
by 2 inches wide at its upper end and received its 
blood supply from a broad pedicle which remained 
attached to the muscle and fascia just below the level 
of the olecranon. After the bony parts had been 
remodeled, the fascia was drawn down and turned in- 
to the joint around the inner margin of the olecranon. 
The proximal portion of the flap covered the 
trochlea, lined the olecranon depression and the 
lesser sigmoid cavity, while the distal portion 
covered the external condyle. Subsequent events 
showed that the flap was not carried sufficiently high 
on the anterior surface of the humerus to permit 
adequate flexion of the joint. Five months later, the 
patient could pass his hand through an arc of 5 
inches. Pronation and supination were about one- 
half normal. His second case was reported 2 months 
after operation. The hand could be moved active!} 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 










Fig. i. 



Fig. 2. 



Fig- 3- 





Fig. 4- 
Fig. i. Line of incision. 
Fig. 2. Dissecting out ulnar nerve. 
Fig. 3. Cutting through the muscle and fascia down 
to the joint. 

through an arc of 3 inches and the elbow forcibly 
flexed to an acute angle and extended to 160 de- 
grees. Pronation and supination were approaching 
normal. 

Hoffa (31), in 1906, reported a series of arthro- 
plasties, seven of which were on the elbow. In one, a 



Fig. 5. Fig. 6. 

Fig. 4. Sawing through olecranon and end of humerus 
Fig. 5. Splitting off tip of olecranon with chisel. 
Fig. 6. Cutting out with rongeur forceps bit of olecranon 
tip left in humerus. 

magnesium plate was used. This operation was un- 
successful owing to the formation of gas in the joint 
causing a fistula which closed only after the rest of 
the plate had been removed from the joint. The 
other operations in which fat, fat and fascia, or fascial 
flaps were used, were all successful. In 2 of these 



SURGERY, GYNECOLOGY AND OBSTETRICS 







£?* 





^ 






Fig. 7. 



Fig. 8. 



Fig. 9. 







W 











Fig. 10. Fig. 

Fig. 7. Scooping out ulna and radius with curette. 
Fig. 8. Cutting fascia lata from thigh. 
Fig. 9. Sewing the flap of fascia lata to the elbow- 
joint anteriorly. 

cases, the ankylosis followed scarlatina; in the others, 
gonorrhoeal infection. 

In 1905, Quenu (56,0) reported a third case in 
which there was great atrophy of the muscles. He 
used for a flap the inner part of the triceps sutured to 



11. Fig. 12. 

Fig. 10. Fascia sewed over humerus; tied with chromic 
catgut suture. 

Fig. 1 1 . Kangaroo suture throug hulna and olecranon tip. 

Fig. 12. Stay sutures. 

the anterior ligament. Passive movements were 
begun in 10 days and later electrical treatment used 
but, as active motion was incomplete at the end of 
2 months, he made a second intervention to recover 
a part of the tendon of the triceps, a large portion of 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 5 




Fig. 13. Case 2. M. R. 
ankylosis before arthroplasty. 



Roentgenogram showing 



which had been sacrificed. He cut the portion inter- 
posed close to the bone. He could then ascertain 
that there was no adherence between the superior 
surface of the interposed segment and the inferior cut 
surface of the humerus. The same condition ob- 
tained on the inferior surface. The tendinous seg- 
ment had left a distinct cavity. The tendon of the 
triceps was sectioned and re-inserted on a little 
fibrous flap previously dissected on the forearm. The 
patient gained not quite complete extension and 
flexion to a right angle. 

Dupuy (20), in 1905, reported 5 arthroplasties. 
Three of these were done by Jeannel, one by 
Kirmisson, and one by Launay. Jeannel used flaps 
of the brachialis anticus; Kirmisson, of the biceps; 
and Launay, a flap from the anterior ligament and the 
brachialis anticus. In all, good results were obtained. 
In two of Jeannel's cases, normal movements were 
obtained ; in the other, the degree of motion was less 
but satisfactory function was gained. In Kirmisson 's 
case, all the movements were present and the function 
good 5 months after the operation. Launay obtained 
passive motion from 80 to 155 degrees with free 
pronation and supination 5 months after the 
operation. 

Huguier (3 5, a), in 1905, reported 2 cases operated 
on by Nelaton, with the interposition of a muscle 
flap. In one case, he gained good motion. In the 
second, re-ankylosis occurred. Huguier reported a 
third case by Ombredanne, by the same method. 

Scudder (63) reported in 1906, 1907, and 190^ 
several cases in which he used Murphy's method 
successfully. 

Pereira (50), in 1906, in an unreduced subluxa- 
tion resected the ends of the bones and interposed a 
flap of triceps muscle with almost perfect functional 
result. 

Bazy (6), in 1907, mobilized an elbow using a flap 
from the brachialis anticus. Nine months later, the 
function of the arm was almost perfect. 

The same year, Stein (64) reported 3 cases from 
Bier's clinic in which triceps flaps were used. All 
were successful. 




Fig. 14. Case 2. M. R. End-result, a. Voluntary 
flexion ; b, voluntary extension ; c, range of motion. 

In 1909, Huguier (35,b) reported an ankylosis 
which he mobilized, using a flap of brachialis anticus. 
Sixteen months later, the patient could touch his 
shoulder with his hand and extend his forearm to 150 
degrees. 

Cifuentes (n) reported in the same year a similar 
arthroplasty in which he obtained a month after the 
operation a good functional result with normal 
movements. 

In 1910, Reiner (58) reported a series of twenty- 
eight arthroplasties, twenty-five of which were given 
in full with the after- results. Two others, recent cases, 
were reported with good immediate results. In three 
others, the histories were unknown. Of the others, 
nineteen gave useful arms, although one was a flail 
joint which lacked power but could be controlled by 
the muscles. The poor results were due in one case, a 
fracture luxation, to extreme atrophy of the muscles, 
and in a tubercular case, to extensive resection of 
the diseased tissue necessary, resulting in a useless 
flail joint. Re-ankylosis occurred in two cases. In 
one, it was due to operation too soon after trauma, a 
fracture luxation, and lack of after-treatment. In 
the other case, the author attributes the result to the 
disease, myostitis ossificans. 

Thorn (68) reported in 1910 a case of ankylosed 
elbow operated on by Ritter. He used freely trans- 
planted fascia lata as an insert after the parts had 
been made freely movable. On discharge, there was 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 15. Case 3. R. T. Roentgenogram showing 
position of ankylosis before arthroplasty. 





Fig. 17. Case 14. W. D. End-result, a, Voluntary 
flexion; b, voluntary extension; c, range of motion. 



Fig. 16. Case 3. R. T. End-result. At left, voluntary 
flexion; at right, voluntary extension. 



65 degrees flexion and 100 degrees extension. 
Pronation and supination which were very slight 
before the operation were unchanged. 

Wille (76), in 191 1, interposed supinator longus 
fascia with good result, gaining 95 degrees motion. 

Whitman (75) reported two cases of arthroplasty 
of the elbow in which he used Murphy's method. 

In 191 2, Edmunds (21) reported an elbow anky- 
losis following fracture in which this method was 
likewise used. At the time of the report, active 
motion was not possible on account of the great 
atrophy of the muscles. 

Denk (19) reported two of von Eisenberg's cases in 
which elbow-joints were mobilized with free fascia 
transplants with good functional results. 

Neff (44) reported a case in which he interposed a 
pedunculated triceps aponeurosis flap between the 
humerus and ulna and the radius and ulna. Seven 
months after the operation, there was active painless 
motion of 180 degrees to 30 degrees and only slight 
lateral mobility. The joints of the wrist and hand, 
which were previously partially ankylosed, regained 
from a third to a half their normal range of mobility 
with the return of function to the elbow. 

Delbert (18), in 1912, reported having done nine 
resections of the elbow with articular grafts. Most of 
these were too recent to determine the results, but he 
reported in detail two cases which were of a year's 
duration and appeared permanent. In one of these 
he used cartilage from an ankle-joint, in the other 
cartilage from an elbow. Both gave good functional 
results. 

Charput (10, a) reported three cases in which he 
resected a flap of fat the size of the palm from the 
thigh and encapsulated the lower end of the humerus 
with it, suturing it tdbthe neighboring muscles by 
anteroposterior and lateral sutures. 

Conrad (12), in 191 2, published a dissertation on 
the use of muscle flaps as interposing material. We 
have been unable to obtain a copy of this thesis. 

Pomponi (53) advocates the use of a pedunculated 
fascial flap by the method of Durante. He cites one 
case in which he gained complete pronation and 
supination, nearly normal extension and flexion to 
60 degrees. 

Murphy (43 ,b) reported among a series of arthro- 
plasties done by him twelve on the elbow by his pe- 
dunculated fat fascia flaps. 

Mauclaire (39) mobilized an elbow, using cartilage 
from the astragalus to cover the defects. One 
fragment was put on the lower end of the humerus, 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 



another between the radius and ulna. A roentgen- 
ogram later showed these grafts fused to the bone. 

Osgood (47) reported sixteen attempts at mobiliza- 
tion by various methods in the different joints. He 
advises against arthroplasty in the hands of un- 
trained operators. 

Putti (55), in 1913, reported his arthroplasties 
to date. These included twelve elbow cases in which 
he used Kocher's incision and a free flap of fascia 
lata. He obtained stabile joints with a useful degree 
of motion. His histological research is referred to 
elsewhere. 

Roepke (59) reported ten cases of ankylosis of the 
elbow in which he did arthroplasties using free fat 
flaps to interpose between the joints. He advised 
against beginning passive motion too soon. One of 
these cases was one of arthritis deformans shown in 
191 1 before the Medical Society of Jena. In others, 
the ankylosis had resulted from trauma, neisserian 
infection, and tuberculosis. 

Exner (22) reported a case fourteen months after 
an arthroplasty in which a free flap of fascia lata was 
interposed. The arm was somewhat unstable but 
gave good function. The patient could lift heavy 
weights. At the same time Pupovac reported a 
second case by the same method. 

Darling (13) reported an arthroplasty with the use 
of a pedunculated flap done in the presence of active 
infection. The immediate result was good. 

Harris (27) discusses the contra-indications to 
arthroplasty. He reports two elbow cases by the 
Murphy method. In one he gained 75 degrees 
motion. In the other, there was 60 degrees motion. 

Turner (71) reported an arthroplasty of the elbow 
for an ankylosis following a severe osteomyelitis. 
There had been a musculospiral paralysis from which 
the patient made a perfect recovery. The elbow had 
entirely healed but, at the time of operation, a small 
area of latent infection was found. Turner used a 
posterior skin incision and inserted a flap of fascia 
lata. The elbow was put up in extension. The next 
day, there was a recurrence of the paralysis with 
signs of local infection. Later, fearing re-ankylosis, 





Fig. 18. Case 5. E. M. Above, Anteroposterior 
roentgenogram after arthroplasty; below, lateral roent- 
genogram after arthroplasty. 

he manipulated the elbow under ether into extreme 
flexion. Six months later, the boy had motion from 
50 to 120 degrees and a useful arm, though the 
muscles were still atrophied. 

The same year Murphy (43, c) reported an arthro- 
plasty by his usual method. The patient left the 
hospital in 5 weeks with free motion within an arc of 
about 45 degrees. 

Vulpius (73) believes that the elbow and hip offer 
the best chances for arthroplasty. He prefers 




a be 

Fig. 19. Cases. E. M. End-result, a, Voluntary flexion; b, voluntary extension; c, range of motion (not full range). 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 20. Case 7. E. S. Roentgenogram showing position 
of ankylosis before arthroplasty. 

pedunculated flaps but also uses free flaps of fat or 
fascia and fat or Baer's membrane. 

In 1914, Payr's (49) oldest case was about 4 years. 
He emphasizes the importance of removing the 
capsule or at least the synovialis as well as the 
fibrous cartilage. Payr has never met with a second- 
ary dislocation nor a loose joint except in some of his 
first knee cases. The initial gain in motion was 
preserved or even increased with use. He had 
trouble with persistent swelling, more especially in 
cases where this had existed before operation for a 
considerable length of time or had been marked. 
He believes convalescence is shortened by waiting 
until the swelling has subsided. If re-operation is 
needed, he advises waiting at least 6 months. He 
reports twenty-two arthroplasties, of which three 
were elbows, one with a good result and two with 
very good results. He believes that if the indications 
are correct and the technique and after-treatment 
good, a favorable result is to be expected in 70 to 
80 per cent. 

Pupovac (54) reported a case of a girl of 19 whose 
elbow had become ankylosed at 130 degrees as the 
result of a severe arthritis. He did an arthroplasty 
using a posterior incision and a free fascial flap, 
gaining motion from 105 to 140 degrees. Five 
months later, he re-opened the joint and removed 
some exuberant bone that united the humerus with 
the ulna, gaining 70 to 130 degrees motion. 

Owen (48) believes that the hip and shoulder offer 
the best fields for arthroplasty. The poorest 
prognosis is in the elbow and knee but if the former 
is ankylosed in extension, operation is advisable, as it 
will at least get the elbow into better position. 

Davis (14) thinks that we should be conservative 
about opening a joint ankylosed by tuberculosis. 
He finds the elbow one of the most satisfactory 
joints for an arthroplasty as well as an excision but 
the results with the former are more brilliant. An 
excision requires the removal of one to one and one- 
half inches of bone to insure movement but, with an 
arthroplasty, only sufficient bone need be removed to 
interpose the flap and it is almost certain to give a 
stabile joint. He uses two pedunculated flaps, one 
from either side. The joint, he believes, should 
have drainage. 



Fig. 21. Case 7. E. S. End-result. At left, voluntary 
flexion; at right, voluntary extension. 

McCurdy (40) advocates the pedunculated flap in 
preference to the free flap, as he believes that the 
nutrition is better and that fascia will slough and 
require removal. He gives no experimental nor 
clinical evidence to bear out this statement. He 
prefers the Baer membrane, as it is more easily 
adjusted and there is, therefore, less blood clot; 
therefore less adhesions and better end-results. 

Murphy (43 ,d) reported in 191 5 a case of ankylosis 
following fracture. The elbow was ankylosed at 
about 150 degrees with a few degrees of motion. 
Seven weeks after operation, there was good pro- 
nation and supination and perfect freedom of motion. 

Ashhurst (4) uses an incision along the external 
supracondylar line and the external condyle detached 
from the humerus with an osteotome. A pedunculated 
flap is inserted and the external condyle replaced 
by means of a Lambotte self-boring screw. He 
reports five cases. In these cases, there were three 
good end-results. One case had a flail joint with very 
slight power of extension. The fifth case had a limit- 
ed motion but the patient refused forcible manipula- 
tion. 

Gilbert (24) cites a case of dislocation of the elbow 
which existed 3 months. Good use of the joint was 
obtained after a Murphy arthroplasty. 

Tubby (70) gives a careful consideration of the 
indications for arthroplasty. He believes that the 
best time for the operation is in early adult life, 
between 18 and 30 years. The mental state of the 
patient must be considered, as co-operation is 
essential; the occupation of the patient must be con- 
sidered; the causative factor must be considered. 
The condition of the soft parts is important. A 
thin, scanty, and scarred skin will not be sufficiently 
nourished to stand the trauma. From the X-ray 
examination, an approximate opinion as to the con- 
dition of the joint is gained. He prefers a muscle 
flap for interposition but has also used fat and 
fascia and Baer's membrane. He does not begin 
passive motion for four weeks but thinks that active 
motion should be begun earlier. He reports one 
elbow case in which he used a muscle flap. At the 
time of the arthroplasty, insufficient bone was 
removed and re-ankylosis took place. Eight months 
later, he did a secondary operation to remove the 
mass of new bone. Following this, all movements 
were free but the elbow was slightly flail. 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 




Fig. 22. Case 8. 
arthroplasty. 



W. D. Position of ankylosis before 



Charput (io,b) reported a case of arthroplasty for 
ankylosis following luxation of the elbow. He used 
two lateral pedunculated flaps and sewed the skin up 
tight. The arm was put up in a sterile dressing in 
extension. The following day, the arm was flexed. 
Mobility returned in 2 days. In 42 days, extension 
and flexion were complete and vigorous. He at- 
tributes the good result to sewing up the wound 
without drainage and the immediate mobiliza- 
tion. 

Graff (25) describes a case in which he interposed 
a flap of triceps muscle with almost complete return 
of normal motion. 

A brief report of an arthroplasty with a peduncu- 
lated flap is given in Kennedy's case (36). The end- 
result is not reported. 

Murphy (43 ,d) reported a case showing perfect 
motion seven months after arthroplasty for ankylosis 
from a fracture. A second ankylosis from tuberculo- 
sis showed a good end- result. 

Whitman (75) exhibited before the New York 
Surgical Society a case in which an arthroplasty had 
been done for a fibrous ankylosis following tubercu- 
losis. Four years before, an arthroplasty had been 
done using a pedunculated flap. At the second 
operation, the fibrous ankylosis was found to have 
become bony. Whitman used a flap of fascia lata at 
this operation. Whitman believes that in an 
ankylosis following tuberculosis, a free fascial 
transplant is essential to success, as the tissues about 
the joint are atrophied. His case showed a perfect 
end-result with normal flexion and 165 degrees 
extension. 

Brown (8) gained 80 to 150 degrees motion in an 
arthroplasty by the Murphy method. The arm had 
been ankylosed in extension following acute meta- 
static arthritis. 

Rovsing (60) reported before the Northern 
Surgical Society 2 successful cases in which the 
Murphy method was used. The ankylosis was the 
result of fracture. In the discussion Bergman and 
Haglund expressed the opinion that mobilization 
of the knee should not be attempted. 

Moszkowicz (42) in his report in 1916 on his 
operations on war injuries to joints, gives among 




Fig. 23. Case 8. W. D. 
ankylosis before arthroplasty. 



Roentgenogram showing 



other cases 6 elbow arthroplasties. In all of these, 
a useful degree of motion was gained. 

Plummer (52) reported two arthroplasties in which 
he used pedunculated fat and fascia flaps. One of 
his cases became infected and subsequently a portion 
of the end of the humerus had to be removed. The 
resulting joint was somewhat flail but gave good 
function. His second case also had good motion but 
his facility for moving the joint was not very good. 

McKenna (41) advocates a modification of the 
Murphy method. He uses a very long flap extending 
well out over the external condyle and an external 
flap for the head of the radius. He believes that 
success is more certain when the arthroplasty is done 
early, as the atrophic changes about the joint are 
less. For this reason, it is important to make a 
correct diagnosis of the infecting agent. The 
gonococcus lives a comparatively short time in the 
joint tissues and an arthroplasty may be done earlier 
in an ankylosis from this agent than in one from 
staphylococcus or streptococcus or a chronic in- 
fection as tuberculosis. In the discussion which 
followed, Gibbons reported an arthroplasty of the 
knee that had come to his notice in which hyper- 
mobility existed necessitating the permanent use 
of a brace. 

Ryerson (61) gives in detail his operative technique 
in arthroplasty on the elbow-joint. He uses a long 
posterior incision avoiding the olecranon. The 
triceps tendon is cut and a thin shell of bone removed 
from the external condyle, taking the origin of the 
extensor with it. Then a shell from the internal 
condyle is removed. The joint is dislocated. After 
it is remodeled, a flap of fascia lata is used to inter- 
pose. 

Thomson (69) reports the end-results in an elbow 
arthroplasty by the Murphy method. Ankylosis was 
the result of sepsis following a fracture. Seven 
months later, elbow motion was good but somewhat 



IO 



SURGERY, GYNECOLOGY AND OBSTETRICS 




a b c 

Fig. 24. Case 8. W. D. End-result, a, Voluntary flexion; b, voluntary extension; 
c, range of motion. 



restricted. His successful cases have all been 
traumatic. He believes that neisserian infection is a 
contra-indication to arthroplasty, as it stimulates 
bone formation. Tuberculosis is also a contra- 




Fig. 25 (above). Case 11. E. S. Roentgenogram show- 
ing ankylosis before arthroplasty. 

Fig. 26. Case n. E. S. Roentgenogram showing 
dislocation after arthroplasty. 



indication on account of the recrudescence of the 
disease. 

Ceccarelli (9) used strips of fascia lata in an 
arthroplasty on a post-traumatic ankylosed elbow. 
The end-result was perfect flexion, extension to 165 
degrees, and almost normal pronation and supination. 

Olivieri (46) reports two arthroplasties with 
interposition of strips of brachialis anticus. The 
end-results were perfect. 

In 1918, Baer (5) reports in full his arthroplasties 
to date, by the use of chromatized membrane. In 
one hundred cases, there were three arthroplasties 
on the elbow-joint. In one of these, re-ankylosis 
took place, one died, and the third showed 25 degrees 
motion. He believes that the elbow is the least 
favorable joint for arthroplasty and that the success 
from the interposition of muscle or fascial flaps is 
due to the amount of bone removed rather than to 
the flap itself and that these operations are in fact 
excisions. In the discussion of this paper, Galloway 
and Freiberg express the opinion that an arthroplasty 
has no advantage over an excision. Davis states 
that with an arthroplasty a more stabile joint is 
obtained. 

Albee (2) uses a vertical incision directly over the 
olecranon. After retracting the ulnar nerve and 
dissecting the soft tissues, he saws through the 
olecranon from within outward. After remodeling 
the joint, he interposes a flap of fascia lata containing 
as much fatty tissue as possible. The arm is put up 
in plaster at right angles. After 10 days, passive 
motion is begun. 




a b c 

Hg. 27. Case n. E. S. End-result, a, Voluntary flexion; b, voluntary extension; c, range of motion. 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT n 




Fig. 28. Case 12. M. D. Motion 4 months after arthroplasty, a, Voluntary 
flexion; b, voluntary extension; c, range of motion. 



Henderson (29), in 1918, tabulated the end- 
results of the 43 arthroplasties done at the Mayo 
clinic. Twenty-one of these were on the elbow. He 
found the prognosis most favorable in the jaw and 
next in the elbow. The knee was the most un- 
favorable position. In reports from other surgeons 
he found a general agreement as to prognosis. 

Kerr (37) reported an arthroplasty of the elbow, 
giving in detail his method of operation. He inter- 
posed some peri-articular fascia. The result was a 
useful, movable joint with no atrophy of the muscles. 

Hohmann (34) reported 5 elbow arthroplasties in 
1918 in which he inserted part of the triceps with 
good immediate results. Lange at the same time 
showed 6 cases in which useful joints were obtained 
and the patients were enabled to resume their old 
occupations. He used fat or muscle flaps. 

Murphy's (43, a) experiments on animals led him 
to conclude that fatty tissue was essential to the new 
joint foundation. This fatty tissue, he believed, 
under pressure formed connective tissue and the 




breaking down of fat globules together with this 
hyperplasia of connective tissue resulted in the 
formation of bursae. Similar results were reported 
by his assistant, Neff. 

Sumita (66), in 20 experiments on dogs, interposed 
muscle and tendon as well as fascia between the 
surfaces of resected joints and found no marked 
difference resulting from the tissue used. 

Davis (15) found that the interposed fascia did not 
degenerate but preserved its normal histological 
characteristics. Putti (55) came to the same con- 
clusions. 

Hohmeier and Magnus (2,2,) obtained the same 
end-results with and without the interposition of 
living tissue. 

Allison and Brooks (3) studied the production of 
joints with free and pedunculated fascial transplants 
and also with chromacized membrane and fascia 
impregnated with silver nitrate. They found no 
difference in the end-result between pedunculated 
and free flaps. They found with Baer's membrane 
the reaction of the surrounding tissues was of such 
intensity that even at the time the membrane was 
disintegrating there were formed adhesions between 
the granulating surfaces. The silver impregnated 
fascia caused relatively little reaction in the sur- 
rounding tissues. 

Steindler (65) found in experiments on a small 
series of dogs that no adhesions were formed after 
scraping the cartilage covering either with the 
insertion of fascia or in controls. Pedunculated 
muscle fascia flaps were transformed with a con- 




Fig. 29. Case 15. L. P. End-result after arthroplasty. 
At left, voluntary flexion; at right, voluntary extension. 



Fig. 30. Case 17. I. H. End-result. At left, volun- 
tary flexion; at right, voluntary extension. 



12 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 31. Case 19. J. T. End-result. At left, voluntary flexion; at right, voluntary extension. 



nective-tissue pannus adherent to the denuded areas 
of the bone. The denuded areas showed lacunar 
reformation of cartilage but no re-formation of bone. 
Phemister and Miller (51) obtained similar results 
in the elbows and knees of dogs whether no inter- 
posing material was used or free or pedunculated 
flaps were used. The flaps largely break down and 
the resulting joints are alike in the three types of 
operation. They do not see how any appreciable 
amount of nutrition can be furnished by the circula- 
tion through the pedicle. They believe that the 
circulation in the surviving portions is through 
adhesions to the parts with which they come in 
contact. 



INDICATIONS AND CONTRA-INDICATIONS 

No attempt at mobilization should be made 
until epiphyseal growth has ceased. If it is 
made before this, it is impossible to 
remove sufficient bone to secure good motion 
without grave danger of injury to the epiphy- 
seal line. Ankylosis is almost sure to result. 

Where the joint has been the seat of an 
infectious process, arthroplasty should not be 
done until all signs of an active process have 
ceased. As a rule, however, we should not 
wait too long, as convalescence is lengthened 
where atrophy of the soft parts from disuse 
is marked. The exception to this rule is in the 



case of a tubercular joint. Here, it is a matter 
of considerable question as to whether an 
arthroplasty should be done. If at all, it 
should be done only very late, a number of 
years after all acute symptoms have subsided. 
Even then we run a risk of lighting up a 
quiescent process. 

OPERATIVE TECHNIQUE 

The arm from the wrist to the shoulder and 
the leg on the same side from the hip to the 
knee are given a two-day preparation. At the 
time of the operation, a tourniquet is applied 
to the upper third of the arm and an applica- 
tion of iodine made to the skin. 

A semicircular incision is then made, be- 
ginning over the external condyle (Fig. 1) run- 
ning down about 2 inches and up over the 
internal condyle. The wound is sponged with 
alcohol and carefully clamped off to avoid 
handling the skin during the operation. The 
flap containing skin and superficial fascia is 
then dissected back to the base line and re- 
tracted. The ulnar nerve is isolated and 
dissected out of its sheath (Fig. 2). It is some- 
times difficult to find this nerve, but it is al- 
ways to be sought at the inner side of the in- 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 13 



ternal condyle. It should be dissected out 
carefully with a blunt dissector so as not to 
break nor injure it. After it has been freed for 
1 . 5 inches, gauze is passed beneath the nerve 
and it is retracted to the ulnar side. It is then 
freed further with blunt dissection with gauze. 

A transverse incision is then made extending 
down through the periosteum (Fig. 3). This 
incision follows in direction the superficial one 
and outlines a flap which is to be dissected 
back and preserved in toto for subsequent 
covering for the joint. The pulling back of 
this flap is a hard and tedious process until it is 
well started, after which it can be peeled back 
readily by blunt dissection. It is the inner 
side that is the hard part, as the layer is thin 
here and we must exercise great care not to 
buttonhole it. The olecranon is then sawed 
through. After this, it is frequently possible to 
break open the old joint. In some cases, 
however, ankylosis is bony and the joint 
cavity obliterated. Cases of this kind are the 
most difficult. It is in these cases necessary to 
saw through the joint. The tip of the olecranon 
has to be chiselled out and dissected back with 
its posterior flap. Usually the olecranon is 
too large and it is well to take off a little of it. 

The capsule, fascia, and ligaments are then 
dissected back so as to allow the lower end of 
the humerus to protrude into the wound 
when its edges are snipped off with rongeur 
forceps and a new trochlear or intercondylar 
surface formed. A shoemaker's rasp is used in 
nling the extremity as near like the normal 
humeral end as possible. After this modelling, 
a piece is removed corresponding to the 
olecranon fossa in the normal humerus. One 
has to be careful about making this cup, as the 
success of the operation depends largely upon 
attention to such small details. This modelling 
is largely done with a saw and a file. 

To insure good function, the joint surfaces 
should fit accurately before the fascia is 
applied, but the joint should not be too loose. 
Only sufficient bone must be removed to give 
free motion. If too much of the ends of the 
bones is removed, a flail joint will result, giving 
the operation no advantage over an excision. 
When this mortising is completed, the fascial 
flap is dissected from the leg (Fig. 8). An 
incision is made on the outer side of the thigh, 




Fig. 32. Case 21. I. L. End-result. Above, volun- 
tary flexion; below, voluntary extension. 

a little below the middle, extending down to 
the fascia lata. After a flap of fascia 5 to 7 
inches long by 4 to 5 inches wide is dissected 
out, the wound is closed. 

This fascia, which is free from all fat, is 
placed about the newly fashioned humeral 
condyles and attached anteriorly to the 
capsule (Fig. 9) and posteriorly to the 
periosteum of the lower end of the shaft of 
the humerus with interrupted chromic catgut 
sutures No. 2. Chromic catgut No. 2 is then 
wound twice loosely around the shaft just 
below the interrupted suture line. 

The forearm is placed in apposition to the 
condyles. Two drill holes are then made in 
the olecranon process and two others opposite 



14 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 33. Case 24. F. A. End-result. At left, volun- 
tary flexion; at right, voluntary extension. 

them in the shaft of the ulna. Through these, 
kangaroo tendon is passed and tied. The 
inner layer is now sutured with chromic 
catgut No. 2 and the skin and fascia with plain 
catgut No. 2. Dry sterile dressings are 
applied and the arm put up in plaster beyond 
a right angle. 

AFTER-TREATMENT 

If there is no evidence of infection, the cast 
should remain on for a week. It is then split 
and the dressing changed. If there is a 
persistent temperature, a window should be 
cut in the cast and the wound inspected. 

Passive motions are begun in about 10 days, 
if normal healing has taken place. The arm is 
always kept above a right angle. After 3 




Fig. 34. Case 25. F. D. End-result. Below, volun- 
tary flexion; above, voluntary extension. 



weeks, gentle massage is applied. Baking is 
begun in 6 weeks, three or four times a week. 
The ultimate success in these cases depends 
very largely on the after-treatment. The 
patients should be under observation for a 
long period of time. Frequent X-rays should 
be taken so that we may follow the bony 
changes in the joint. If motion begins to shut 
down, the arm should be manipulated under 
an anaesthetic and the elbow put up in acute 




Fig. 35. Case 26. S. S. 
ankylosis before arthroplasty. 



Roentgenogram showing 



Fig. 36. Case 26. S. S. End-result. At left, volun- 
tary flexion; at right, voluntary extension. 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 15 



flexion. Occasionally, motion becomes limited, 
due to an exuberant growth of new bone. 
In this case, a secondary operation should be 
done to remove this, but it should not be 
undertaken for at least 3 months after the 
original operation. 

Case i. F. P., December, 1909, fell on her elbow 
in March, 1908. The injury was treated as a sprain 
and the elbow put up in a splint. She recovered 
except for a slight stiffness and pain, but as time 
went on the motion became less. Later, she was 
under observation for 6 weeks in the out-patient 
department. 

On November 18, 1908, an attempt was made to 
gain motion by removing as much exuberant bone as 
possible. Following the operation, the patient 
suffered from a Volkmann's paralysis. She made a 
splendid recovery from this paralysis but, un- 
fortunately, on account of the sensitiveness of the 
elbow, there was not so much motion as before the 
operation. An arthroplasty was therefore advised. 
This I did in December, 1909, using the Murphy 
method. 

The circulation of the skin above the original site 
of the flaps became somewhat diminished and there 
was a small amount of sloughing. The wound was 
dressed each day and on the fifth day daily attempts 
at motion were begun. In the course of a month, 
massage and baking were again taken up and con- 
tinued until May, 1910. 

The patient was last seen April n, 1919. She had 
at this time motion from 45 to 125 degrees and no 
tenderness. Except for extension, the result was 
perfect. Previous to her marriage, she had used her 
arm daily in her employment as a stenographer. 

Case 2. M. R. for 13 years had had attacks of 
rheumatism affecting the ankles, elbows, and knees. 
The physical examination was negative except for 
the joints. Both knees were slightly flexed and the 
right one was ankylosed showing scars on either side. 
The right ankle showed some contraction of the 
tendo achillis. The left elbow showed good motion 
except for 10 degrees limitation in extension; the 
right was ankylosed at 125 degrees. 




Fig. 37. Case 27. N. B. Roentgenogram showing 
position of ankylosis betore arthroplasty. 

The patient was admitted to the orthopedic service 
of the Carney Hospital, September 6, 1910, where 
very slight improvement took place in her knees and 
feet under conservative treatment. In October, on 
account of the swelling and bogginess of the left knee, 
an arthrotomy was advised. This was done October 
19. Daily manipulations were begun on the fifth day, 
and an uneventful recovery took place as regards the 
knee. 

As the elbow was stiff and in an ungainly position, 
operation on this joint was advised. On November 
5, 1 910, an arthroplasty by the Murphy method 
was done on this joint. 

November 10, the right hand was considerably 
swollen and painful, for which pressure and hot 
fomentations were applied. The skin on the upper 
part of the arm became somewhat necrotic from poor 
circulation and later sloughed. 

November 30, passive motion was begun and 
repeated daily. The first attempt was made at 
motion, when 30 degrees were attained. Following 
this, progress was continuous and a gradual gain in 
motion was made. Later, massage was ordered for 
the hand, forearm, and shoulder. 

January n, 1 9 1 1 , about 30 to 40 degrees of motion 
in flexion and extension were obtained. The wound 
showed heavy granulation tissue. A week later she 




Fig. 38. Case 27. N. B. End-result. At left, voluntary flexion; at right, voluntary extension. 



i6 



SURGERY, GYNECOLOGY AND OBSTETRICS 




Fig. 39. Case 28. W. M. End-result. Below, volun- 
tary flexion; above, voluntary extension. 

was discharged from the hospital. Dressings were 
to be done at home. 

February 28, she was readmitted to the hospital for 
manipulation when normal motion was obtained. 

March 13, the patient was discharged to continue 
massage and manipulation at home. Since this time, 
she has been seen in the out-patient department. 
There is practically no lateral mobility and the end- 
result is perfect function. 

Case 3. R. T. In this case, ankylosis had followed 
a fracture 5 years previously. A year and a half 
before, an attempt was made at the Massachusetts 
General Hospital to gain motion by open operation, 
followed by Zander treatment and baking. At the 
time when I first saw her, there was no pain in the 
arm but the stiffness was increasing. For this, an 
arthroplasty was advised. 

On July 26, 191 1, I did an arthroplasty by the 
Murphy method. The ether recovery was good but 
the patient showed a mild paralysis of the ulnar 
nerve which disappeared 2 days later. 

The wound was dressed daily, when it showed 
considerable discharge of fat necrosis, but no infec- 
tion was apparent. The arm was very sensitive and 
painful on movement. The motor power of the third 
and fourth fingers was restored but sensation was still 
slightly impaired. Following this, recovery was 
uneventful, and patient was discharged from the 
hospital on August 19 to report to my office. 

October 24, the patient was readmitted to the 
Carney Hospital for manipulation, which was done 
the following day. She was discharged on October 
26 with the arm in acute flexion. 

February 18, 1914, the patient could extend the 
elbow to 165 degrees and flex to 25 degrees. The 



patient plays the piano and does all her house- 
work. 

Case 4. W.D. was referred to me by Dr. A. W. 
Shea of Nashua, New Hampshire, and was operated 
upon before the New Hampshire Surgical Club. 
On March 25, 1911, he received a contused wound of 
the left thumb, which became septic, requiring, 1 
week later, his entrance to the hospital, as sepsis had 
become general. Five incisions were made in the left 
hand, two in the left wrist, one close to the left 
elbow-joint, and one in the left hip. All had drains 
put in. A student in the hospital opened a swelling 
near the right elbow and cut into the joint. At the 
end of 2 1 weeks the patient was discharged from the 
hospital with bony ankylosis of the right elbow with 
but a few degrees of motion in the left elbow. Both 
joints were slightly flexed. The left wrist had a sinus 
which still drained a little and he had little motion 
in the fingers, being unable to flex them to a right 
angle with the palm of the hand. He was unable to 
feed himself or to touch his head with either hand. 
He entered St. Joseph's Hospital a few weeks later 
and I did an arthroplasty on his right elbow, in 
March, 191 2, using a flap of fascia lata to interpose. 
A hard bony ankylosis was found. The skin was 
closed with silkworm-gut and a voluminous dressing 
applied with the arm at a right angle. Arm and 
forearm were placed on pillows with heavy dressings 
but no splint. Passive motion was begun on the fifth 
day. Primary union took place in the wounds of the 
elbow and thigh. Passive motions were continued 
and increased, but at the end of 6 weeks it was found 
that the patient could not use either biceps or triceps 
muscles and he had lost all power from long disuse. 
However, after several weeks he educated the 
muscles by counting and attempting contraction at 
the same time and finally was able to flex the forearm 
himself, since which time improvement has continued. 

He has now full motion in flexion, extension, and 
rotation and is able to feed himself and to do chores 
about the house and put on his own clothes. Previous 
to operation, he was entirely helpless, unable to care 
for himself in any way. 

Case 5. E. M. Two years before, the patient 
became ill with infectious arthritis which at first 
affected the knees. The trouble started slowly with 
general poor health. There was no history of a 
neisserian infection but the patient was very much 
constipated and suffered more or less from tonsillitis. 
Later, the elbows became painful and could not be 
straightened out. 

Physical examination showed a thickening of the 
capsule of the left elbow, with about 35 degrees 
limitation in motion. The left knee showed extension 
to within fifteen degrees of straight. The patient 
walked with a marked limp and flexed knees. 
General treatment was prescribed, with forcible 
extension of the knees. As motion in the arm had 
shut down leaving it ankylosed at 100 degrees, an 
arthroplasty on this joint was advised. 

February 25, 1913, 1 did an arthroplasty, using my 
fascia lata method. 






MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 17 



March 24, the arm showed no swelling. There was 
little pain and the patient's general condition was 
fair. There was about 15 degrees motion. Gentle 
manipulation was ordered. 

December, 16, the wound had healed by first 
intention; supination was three-quarters normal, 
extension was to 170 degrees and flexion to 10 to 15 
degrees beyond a right angle. The patient could 
reach the opposite shoulder with the thumb with ease 
but could not dress the lower part of the hair. The 
muscular power was as good as in the right arm. To 
gain more motion, a forcible manipulation was 
advised. 

December 29, under ether, extension to within 
five degrees of straight was obtained and flexion to 45 
degrees. 

January 26, 1914, examination of the arm showed 
no lateral mobility and no crunching crepitation. 
Mobility was from 150 degrees to 70 degrees. 

December 10, 1914, the patient showed vol- 
untary motion from 55 degrees to 145 degrees. 

Case 6. M. B. was admitted to the House of 
Mercy Hospital, Pittsfield, June 15, 1913, suffering 
from a bony ankylosis of the right elbow. Two days 
later, I did my usual arthroplasty putting up the arm 
in plaster in full extension. Recovery was uneventful. 
The arm was twice manipulated under ether, on 
July 29 and on August 13 to gain further flexion. 
She was discharged September 24, wearing her arm 
in a short sling. This was a clinic case and I have 
been unable to obtain any later data on the case. 

Case 7. E. S. was admitted to the Carney 
Hospital, August n, 1913, for immobility of the 
right elbow and right knee. Six years previously, the 
patient had had an acute illness accompanied by 
fever and pain and swelling in the joints, for which 
she was treated in her home, without relief. At the 
end of 8 months, the pain and swelling had dis- 
appeared from her left shoulder and elbow so that 
she was able to feed herself, but she remained in bed 
for 12 months and after this was in a wheel-chair for 
2 years. The symptoms continued to subside on the 
left side until at the end of the third year, she was 
able to get about with a cane. As the fever continued 
to subside and the pain and swelling disappeared, 
fairly good motion returned to all the joints except 
the right elbow and the right knee, in which pain and 
stiffness continued at the end of the fourth year and 
no motion was possible. This condition continued up 
to the time of admission. August 14, roentgenoscopy 
revealed an ankylosis of the elbow-joint and of the 
patella to the femur. 

August 20, 1 did an arthroplasty of the right elbow, 
using a flap of fascia lata. A light plaster cast was 
applied. Following the operation, the patient made 
a good ether recovery. There was slight pain in the 
elbow. 

August 27, the cast was split for dressing. 

September 1, the wound had healed by first in- 
tention except for a slight discharge on the upper 
border. September 4, daily manipulation of the 
elbow was ordered. 



September 10, the arm could be extended com- 
pletely and flexed to 15 degrees beyond a right angle. 

September 15, traction was applied for flexing and 
extending the arm. 

October 1, active motion was possible. 

October 15, I manipulated the arm under ethyl 
chlorid. 

She was discharged from the hospital. May 15, 
1919, 5 years and 10 months after operation, she 
writes "the arm is doing excellent work." Photo- 
graphs taken at this time show practically full ex- 
tension and flexion. 

Case 8. W. D. The previous history of this case is 
given under Case 4. After the arthroplasty on the 
right elbow, the patient requested that a similar 
operation be done on the other elbow. The roentgen- 
ogram showed a bony ankylosis at 90 degrees. On 
January 31, 1914, I did an arthroplasty on the left 
elbow-joint, using the same method applied in the 
case of the right elbow. The end-result was a stabile 
useful elbow, with motion from 60 to 160 degrees. 

Case 9. R. B. was seen in consultation March, 
1914, suffering from partial loss of function of the left 
elbow, as the result of an old fracture of the olecranon 
and external condyle and was unable to extend the 
elbow beyond a right angle, with supination limited 
one-fourth. An arthroplasty was advised. 

This was done at the Carney Hospital on March 
17, 1 914. The usual technique was used and the arm 
put up in a sterile dressing in extension. The boy 
made a good ether recovery, slept well, and suffered 
no pain. 

The wound remained clear until the 23d when it 
appeared reddened and showed some discharge. The 
following day, the axillary glands were tender to the 
touch and the hand showed some oedema. Hot 
poultices were applied. 

By the 27th, the pain was relieved and the glands 
were not palpable. The wound was clean. Two silk- 
worm-gut sutures were applied to prevent the 
spreading of the wound. 

On March 31, a plaster cast was applied from 
axilla to finger tips in 1 5 degrees flexion and one-half 
supination. 

On April 1, manipulations were begun and con- 
tinued daily. 

On April 11, the patient showed full pronation and 
supination but only about 45 degrees flexion. 

On April 18, a splint was applied to increase 
flexion. 

On April 23, I gained 45 degrees flexion, putting 
the elbow up in plaster in acute flexion. This cast 
was split on April 29. On May 1, the arm was put up 
in plaster at 10 degrees' flexion. A window was cut 
in the plaster and the wound dressed. The patient 
was then discharged to have the arm dressed by his 
family doctor. I have been unable to obtain later 
reports on this case. 

Case 10. E. E. had fractured his elbow 8 years 
before. He entered the Massachusetts General 
Hospital 1 1 days later. The roentgenogram showed a 
supracondylar fracture, probably epiphyseal, with a 



i8 



SURGERY, GYNECOLOGY AND OBSTETRICS 



good deal of displacement of the lower fragment. A 
closed reduction was attempted under ether and the 
elbow put up in plaster with only a little flexion. 
Seven weeks later, he re-entered the hospital. At 
this time, the X-ray showed a very faulty position 
with some ankylosis of the joint. An osteotomy of 
the joint was done and the arm elevated. The arm 
was put up at an angle of about 150 degrees and the 
patient discharged to the convalescent home. 

Three weeks later, he re-entered the hospital. At 
this time the elbow was swollen and very tender. 
The elbow was incised and the abscess drained and 
hot soaks ordered. He was discharged a month later. 

Two months later, he re-entered the hospital for 
persistent sinuses in the arm, which were incised and 
drained. A week later, he was discharged relieved. 

The patient entered the Carney Hospital Novem- 
ber 28, 1913. At this time there was considerable 
atrophy of the arm and forearm. The elbow was 
ankylosed at 85 degrees and showed the scars of the 
previous operations. Ether manipulation was done 
on the wrist and later on the elbow. 

Later, December 24, 1913, an excision of the semi- 
lunar, scaphoid, and pisiform was done. 

On January 14, 1914, 1 did an arthroplasty on the 
elbow. At the time of the operation, the ulnar nerve 
was not found in its usuai bed, probably having 
undergone degeneration. No bony landmark could 
be made out. 

He made a good* recovery from the operation. 
The wound remained clean but showed a slight serous 
exudate. Later, the wound showed a slight slough. 

The elbow was manipulated on February 20, 
gaining motion to a right angle. 

Five weeks later he was discharged to be treated 
by his family physician. 

This case was not seen again until recently, when 
he showed a fibrous re-ankylosis with marked 
muscular atrophy. 

Case ii. E. S. sustained a fracture of the right 
elbow on October 4, 1913, as the result of a fall of 42 
feet. The roentgenogram showed a transverse 
fracture of both condyles with the radial head 
dislocated laterally and anteriorly. 

Physical examination was negative except for the 
right arm. The shoulder appeared normal. The 
elbow was held at 150 degrees extension with less 
than 3 degrees motion. Supination was limited one- 
fourth. The wrist showed a Colles fracture un- 
reduced. Flexion and extension were both one-half 
normal. Eversion was limited three-quarters and 
inversion four- fifths. 

On March 25, 1914, I did an arthroplasty on the 
right elbow, using a flap of fascia from the thigh. 
When the joint cavity was opened, it was found that 
the synovial tissue was hypertrophied and there was 
much fibrous callus formation infiltrating the 
articular surfaces. A transverse fracture of both 
condyles was noted. The head of the radius was 
impacted and was surrounded by callus formation. 

Five-eighths of an inch of the condyles was sawed 
off square at right angles to the shaft of the humerus. 



The joint surfaces were smoothed off and the operation 
completed according to my usual method. The arm 
was put up in plaster in an extended position. The 
patient made a good ether recovery but suffered 
considerably from pain, for which morphia was 
ordered, and the following day the arm was put up in 
suspension. He continued to suffer considerable 
pain for four days, after which the pain abated. 

On March 29, the wound was dressed and was 
found clean with some serous discharge. 

March 30, the cast was split and a voluminous 
dressing applied with splints to the forearm. 

March 31, the patient was seen in consultation by 
Dr. Courtney, who reported a tourniquet paralysis 
and advised electricity and massage. 

April 1, the wound was dressed and found clean 
and healing by second intention. 

April 5, the patient was out of bed and walking 
about the ward. When dressed, the wound was found 
clean. 

April 10, the wound was dressed. The motion in 
the elbow was good with good supination and about 
45 degrees flexion. A nerve report was ordered. 

April 15, the nerves were reported responding to 
the faradic current. The prognosis was considered 
good. Massage was advised. 

April 18, the patient was discharged from the 
hospital to report daily at my office. 

November 30, the patient re-entered the hospital 
for operative interference in an attempt to gain 
increased motion. Both bones of the forearm had 
dislocated backward and the head of the radius was 
very much enlarged. Motion was from 150 degrees 
to 50 degrees with the carrying angle markedly 
increased. 

On December 2, after the usual preparation, a 
4-inch incision was made over the external condyle. 
The removal of the enlarged head of the radius 
caused a marked increase in motion but the posterior 
dislocation was not improved. The internal condyle 
was chiseled loose and removed through a small 
incision over the fragment. After the end of the 
humerus was smoothed as much as possible with a 
rasp, the wound was closed and a cast applied with 
the arm at right angles. A good ether recovery 
followed. 

After the operation, the patient suffered con- 
siderably and showed some swelling of the arm. 
On the fourth day, the cast was split, when the 
patient experienced relief. 

On the 7th, the patient was comfortable and out of 
bed. The following day he was discharged to report 
to my office. The end-result shows nearly normal 
range of motion with a stabile, useful joint. 

On October 29, 1920, he writes: "I can crank a 
Ford. I can do anything that I ever could. My work 
is driving and repairing automobiles and I have had 
to change a 38-7 tire on the road, which requires the 
use of two good arms. " 

Case 12. M. S. had suffered from a chronic 
arthritis, probably a neisserian infection, affecting 
both wrists, the left knee, and the right elbow. The 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 19 



trouble had begun 4 years before and was gradually- 
getting worse until she was unable to work. The left 
knee showed thickening and slight heat. It was held 
in 45 degrees permanent flexion and showed only 
10 degrees motion. Her left wrist was ankylosed. 
The right elbow was ankylosed at right angles and 
was painful at one-half supination. 

The patient entered the House of Mercy Hospital 
on June 18, 1914, where an arthrotomy followed by 
oil injections was done on the knee and an arthro- 
plasty on the elbow. Four months after arthroplasty, 
the patient showed a range of motion from 60 to 140 
degrees and a stabile, useful joint. 

Case 13. M. F. had a severe polyarthritis when 6 
years old. At this time, she was under treatment at 
the Holyoke City Hospital for 10 weeks, receiving 
general treatment from which she experienced 
temporary relief. Since then, she has suffered 
recurrent attacks of acute arthritis. 

When she entered the Carney Hospital on April 
23, 1914, physical examination showed an involve- 
ment of her elbows, wrists, fingers, knees, and 
ankles in the infectious process. Motion was limited 
and the joints were swollen and contained a small 
amount of fluid. The elbows were ankylosed at 
125 degrees. Consultation was held with the 
medical, surgical, and laryngological staffs, whose 
reports were negative, except in regard to the tonsils. 
Following their removal on May 16, she showed 
marked improvement in the hands and feet under 
conservative orthopedic treatment. 

On June 10, her wrists, ankles, and knees were 
manipulated under ether. From this operation, she 
made an uneventful recovery. 

As her elbows were ankylosed, an arthroplasty was 
advised on the right elbow. This I did on July 1 by 
my usual method. She made an uneventful recovery 
and on July 26 showed motion from 50 degrees to 
almost normal extension. Flexion later increased to 
within 15 degrees of normal. 

On August 12,1 manipulated the arm and put it up 
well beyond a right angle. On August 19, the elbow 
could be manipulated without force to beyond a 
right angle, with force to within 5 degrees of full. 
Following this, however, motion gradually shut down 
and the end-result was re-ankylosis. I believe that 
this result is to be expected in children, on account 
of the impossibility of removing sufficient bone 
without injury to the epiphyses. 

Case 14. A. M. had suffered from infectious 
arthritis for 10 years. Her fingers, knees, and elbows 
had become stiff. 

Physical examination was negative, except for the 
joints. The right elbow was ankylosed at 90 degrees 
with about 30 degrees motion. The wrists were 
ankylosed in slight flexion. Previous to the arthro- 
plasty, her feet and knees were manipulated. 

On November 14, I did an arthroplasty, inserting 
a flap of fascia lata. Convalescence was unevent- 
ful. 

On February 10, I manipulated the elbow under 
ether, holding the elbow in acute flexion with bands 



of adhesive. She was discharged from the hos- 
pital on April 2 with motion from 45 to 100 
degrees. 

Case 15. L. P. I saw the patient for the first time 
July 10, 1914. The trouble had begun November 23, 
1912, when she was confined in bed with a tempera- 
ture of 102 ° and swelling of the wrists and ankles. 
It had progressed ever since in spite of orthopedic 
and other treatment. 

Physical examination showed marked involvement 
of all the joints of the arms and legs with ankylosis 
and more or less pain and swelling. The left wrist 
was ankylosed at 35 degrees radial adduction and the 
left shoulder showed a bursitis. The left elbow 
showed a few degrees motion and was held rigidly 
at about 135 degrees extension. 

The patient was advised to have the shoulder 
manipulated and put up in plaster and to have the 
deformity of the wrist corrected. For the elbow, an 
arthroplasty was advised. 

On July 10, I did an ether manipulation of the 
hips, knees, and feet. 

January 13, 1915, an arthroplasty was performed 
on the left elbow. The olecranon was found anky- 
losed to the humerus. Both humerus and ulna 
showed a large amount of bone atrophy. 

On October 13, I operated on the wrist for 
ankylosis. I excised the heads of the first phalangeal 
joints of the four fingers besides the distal metacarpal 
head of the thumb and fourth finger. 

On February 6, 1916, I did an excision of the 
shoulder. 

The latest report on this case is July 23, 1919, at 
which time flexion was perfect; when standing or 
sitting, complete extension is possible. The action 
of the elbow, however, below a right angle is weak, 
due to muscular atrophy. 

Case 16. G. F. The trouble began 8 years before 
with an infectious arthritis affecting the fingers of 
the right hand. Later, she had other attacks in- 
volving the other hand, the feet, ankles, and knees. 
About a year before she entered the hospital, she 
was confined to her bed for 8 weeks with an attack 
involving the elbows, hands, and ankles. Sub- 
sequent to this, the mobility in her hands and elbows 
had diminished. She entered the Carney Hospital on 
December 27, 191 3, for relief of this condition. 

Physical examination at this time showed marked 
involvement in the arthritic process of the elbows, 
fingers, ankles, and toes. The right elbow was 
ankylosed at 155 degrees. The left elbow showed 
motion from 160 degrees extension to 45 degrees 
flexion. 

The patient received general treatment and was 
referred to the surgical department for an ileo- 
sigmoidostomy. She left the hospital relieved 
following this operation. 

In January, 191 5, she re-entered the hospital for 
relief of the stiffness of her joints. Since the ileo- 
sigmoidostomy, her general health has improved. 
Her joint condition, however, has remained un- 
changed. 



20 



SURGERY, GYNECOLOGY AND OBSTETRICS 



Physical examination showed the right elbow 
permanently ankylosed, the left ankylosed at 90 
degrees with 5 degrees motion. 

On January 20, 191 5, 1 did my usual arthroplasty 
on the right elbow. She made a normal recovery and 
left the hospital with a good amount of motion. 

After she left the hospital, she had another acute 
attack of arthritis which affected this joint. Gradual- 
ly, motion became more painful and shut down. For 
this condition, she re-entered the Carney Hospital. 
The X-ray showed anteriorly the development of 
new bone. A secondary operation was done at which 
the head of the radius was removed as well as the 
exuberant bony tissue. 

Case 17. I. H. had fallen on her elbow 4 months 
before she entered the hospital. She had suffered 
considerably from pain and was unable to use her 
arm. At this time, I manipulated her elbow under 
ether and later manipulated it every 2 weeks in the 
Carney out-patient. On account of the limitation in 
motion, an arthroplasty was advised. 

She entered the Carney Hospital on June 22, 1915. 
At this time, the elbow was slightly tender and 
motion was limited to forty degrees. There was no 
pain but the joint was somewhat enlarged and the 
bones felt rough. The roentgenogram showed an old 
fracture of the lower end of the humerus. 

On June 23, I did an arthroplasty of the elbow- 
joint, using a free flap of fascia lata, after which the 
patient made a good ether recovery. The following 
day, the plaster was trimmed about the fingers. The 
fever and swelling of the hand continued for several 
days until, on the 28th, the cast was bivalved, when 
the temperature dropped and the oedema disappeared. 

On July 3, the patient was up in a chair. On the 
6th, the dressing showed a slight superficial sepsis. 
The motion of the arm was very much increased. 
She was discharged from the hospital on July 15, to 
report to the out-patient department. Following 
this, there was a gradual return of motion. 

In June, 1919, 3 years after the operation, she 
showed a range of motion from 37 to 125 degrees. 

Case 18. D. S. While playing basket ball, the 
patient had been pushed against the wall, injuring 
the right elbow. He suffered a good deal of acute 
pain immediately following this and soreness had 
persisted for several weeks. The elbow had gradually 
become stiff. Twelve months before this, D. S. had 
had an acute condition in the elbow, when it was hot 
and painful, but quieted down quickly. 

Physical examination showed the right arm held in 
about 105 degrees flexion. About one-fourth pro- 
nation was allowed and supination was limited one- 
half. The patient's grip was good and he had 
apparently full use of the fingers and hand. There 
was very slight capsular thickening and the fossae 
on either side of the olecranon were not as sharp as 
normal. The musculature of the arm was good. 
Sudden jerks in flexion and extension were painful. 

Arthroplasty was advised. This was done by my 
usual method at the House of Mercy Hospital, 
Pittsfield, September 23, 1915. 



The patient was last seen 2 years after the opera- 
tion. He has been working with the General Electric 
Company and has been admitted to the National 
Guard. He states that in damp weather he has a 
little aching pain and cannot do heavy lifting. 
He can dress himself. In October, 191 7, while 
playing a game, his arm was strained and something 
snapped, but he was able to keep on playing. The 
fingers got a little stiff afterward with pain up the 
arm. The weakness and inability to use the arm 
lasted 4 weeks but was followed by perfect re- 
covery. 

The arm at this time showed extension to 125 
degrees and flexion to 20 degrees, pronation 
one-half. Musculature was good. He shows a 
perfect functional result. 

Case 19. J. T. One year before the arthroplasty, 
his right arm had been severely burned while he was 
at work in a paper mill. The burn had become 
septic, resulting in marked contraction of the scar 
tissue for which an extensive skin graft had been done 
with very good result. His elbow, however, had 
remained stiff. 

Physical examination was negative except for the 
right arm. The scar tissue extended from the fingers 
to the axilla on both anterior and posterior surfaces. 
The thumb was abducted one-half and the fingers 
held in hyperextension. They could, however, be 
flexed. 

On October 4, 191 5, I operated upon the elbow 
doing an arthroplasty with a flap of free fascia. At 
operation, the ankylosis was found to be fibrous. 

The patient made a good recovery from the ether. 
The wound was dressed on the second day when it 
was found clean, but the skin suggested a slough in 
the middle of the incision. He was discharged from 
the hospital on the 2 2d after an uneventful recovery. 

Two months later, the elbow showed a range of 
motion from 45 to 140 degrees and was free from pain. 

Case 20. J. C. The right elbow had become stiff 
following an acute infection of the entire arm. Later, 
there had been a discharging sinus near the elbow- 
joint. 

Physical examination was negative except for the 
right arm which showed some atrophy. All motions 
of the shoulder were normal. The elbow was solidly 
ankylosed at 165 degrees. Motion of the hand was 
limited. The X-rays showed a bony ankylosis of the 
elbow-joint. 

On February 27, 191 7, 1 did an arthroplasty by my 
usual method. This case was unusual in that the 
remodeling was very difficult. Ordinarily, after 
the olecranon has been sawed through, you can break 
open the joint or, at least, there is soft bone that is 
readily sawed through. But in this case, the joint 
was solidly ankylosed and every vestige of the joint 
had disappeared. 

Following the operation, the wound showed some 
bloody oozing. On March 5, a window was cut in the 
cast and the wound was found healed and clean. 
The patient was out of bed on the 10th and 7 days 
later was discharged from the hospital. Baking and 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 21 



massage were continued. The end-result was a 
stable elbow with good function. 

Case 21. I. L. Her left elbow had become 
ankylosed as the result of an arthritis of 10 months' 
duration. When I first saw her, October 3, 1916, her 
elbow was very sensitive and painful. About 10 
degrees motion was allowed in the joint which was 
held in 130 degrees extension. Supination was about 
one-third normal. 

In spite of conservative treatment, the elbow con- 
tinued to stiffen. As a roentgenogram taken 
February 17, 1917, showed a bony ankylosis, an 
arthroplasty was advised. This was done March 6, 
191 7, and was followed by an uneventful recovery. 

Miss L. was last seen May 26, 1919. She stated 
that only occasionally did she have slight pain. 
Motion in the elbow was from 45 to 145 degrees and 
she had a stable, useful arm with no lateral mobility. 
Rotation was limited to 15 degrees in the mid- 
position. This loss of motion is apparently due to the 
enlargement of the head of the radius and its 
excision was advised. 

Case 22. CM. had a complete bony ankylosis of 
the left elbow in 145 degrees extension. The condition 
had existed for 17 years, since the patient was 14 
months old, when she had broken her arm. The 
X-ray showed a complete obliteration of the joint. 

On August 23, 191 7, I did an arthroplasty at St. 
Luke's Hospital, New Bedford. After an uneventful 
recovery, the patient was discharged a week later to 
report weekly to the out-patient department. 

On September 6, the cast was split and the wound 
dressed. The patient had 15 degrees motion. Her 
arm was put up in a sling and she was asked to 
manipulate the arm and report again in 2 weeks. 

September 27, she returned and was advised to 
continue treatment. 

On October 11, the patient did not show much 
gain in motion. She admitted that she was not 
carrying out instructions regarding exercising the 
arm . She was advised to have an ether manipulation. 

October 25, she reported at the hospital but again 
was found not to be carrying out instructions. 

November 1, she showed a slight improvement. 
She was advised to increase her exercises. 

November 8, she was referred to the hospital for 
an ether manipulation. 

December 20, she was again advised to have the 
elbow forcibly manipulated. 

January 3, 1918, an ether manipulation was done 
and the arm strapped up in 30 degrees flexion. 

On January 10, the patient reported and was 
found to be doing well. She was asked to report each 
week. 

When the patient reported again a week later, she 
was found to be again not following directions. A 
further manipulation was advised. 
_ On January 31, she visited the clinic for the last 
time. Manipulation was again advised. Since this 
time, she has been seen several times by our social 
worker and urged to return for further treatment, 
but this she has steadily refused to do. She is work- 



ing daily in a mill. When last seen, May 19, 1919, 
she stated that she felt the arm would have been all 
right if she had come again for operation, but was 
afraid of the pain and her mother did not want her to 
go again to the hospital. This case shows the 
necessity of the co-operation of the patient in the 
after-treatment. 

Case 23. M. R. fell on January 12, 1918, fractur- 
ing her elbow. Splints were applied at this time and 
remained on for 3 weeks. On March 7, an operative 
attempt was made at the Brockton Hospital to gain 
motion. I first saw Miss R. on June 4, 1918. At this 
time, her elbow was swollen and painful and allowed 
motion only from 155 to 160 degrees. It was held in 
permanent pronation with no motion in the radio- 
ulnar joint. There was a slight discharge. 

A few weeks later she entered the Carney Hospital 
and on June 27 I manipulated the arm and applied a 
cast which was kept on 4 days. She was then dis- 
charged with her arm in a sling. 

As the arm again stiffened, she re-entered the 
hospital February 10, 1919. At this time, her elbow 
was ankylosed at 90 degrees. On February 12, 1 did 
my usual arthroplasty. The soft tissue surrounding 
the joint presented a mass of scar tissue from which 
the ulnar nerve could not be isolated. The tissue 
through which the nerve must have run was there- 
fore dissected back and retracted en bloc. The line of 
the old joint was discovered with difficulty. 

The patient made a good ether recovery and was 
fairly comfortable the following day after some pain 
on the previous night. The cast was stained through 
by the discharge from the wound. 

On February 14, a window was cut in the cast over 
the area of operation and a sterile alcohol dressing 
applied. The bloody discharge from the wound still 
continued on February 17. This condition remained 
unchanged until the 26th, when the wound showed 
some healing upon the outer side of the elbow. On 
the 28th, the discharge had decreased in amount but 
the dressing showed a slight amount of pus on the 
inner side. 

On March 4, motion was possible from 80 to 105 
degrees without pain. 

On March 10, the arm was put up in a sling in as 
acute flexion as possible and daily manipulation of 
the fingers begun. The wound was still discharging. 

On March 24, the discharge had decreased slightly 
in amount. The finger motions had increased. 

On March 3 1 , the condition was unchanged. Light 
massage was begun on the upper and lower arm. 
Dressings were continued twice a day. 

On April 7, the arm was put up in a sling at about 
70 degrees flexion. There was still a discharge. On 
April 14, there was some swelling back of the elbow- 
joint but no fluctuation was felt. The arm was kept 
quiet and the swelling subsided in a few days. The 
discharge gradually decreased, and on April 20 the 
patient was discharged to have the dressings done by 
her local doctor. 

Case 24. F. A. suffered on May 30, 1916, from a 
severe osteomyelitis of the left humerus. The arm 



22 



SURGERY, GYNECOLOGY AND OBSTETRICS 



was incised at this time and a sequestrum removed. 
Since then, his general condition had improved but 
he had suffered from wrist-drop since the operation, 
and motion in the elbow had been lost. 

When A. was referred to me, the arm showed a 
seven and one-half inch scar on the outer aspect. 
There were two sinuses which discharged creamy pus. 
The shoulder motions were one-half normal. The 
elbow was slightly thickened and showed local heat. 
It was ankylosed at no degrees with a few degrees 
motion. There was complete wrist-drop. X-ray 
showed a diffuse osteomyelitis involving the whole 
humerus with some evidence of sequestrum forma- 
tion in the upper third. A subperiosteal resection of 
the shaft of the humerus was done. From this opera- 
tion, he made a good convalescence. 

On August 15, 1917, the arm showed the scar 
healed. There was apparently a total regeneration 
of the humerus. The shoulder showed 45 degrees 
motion in abduction with good anteroposterior 
movements. The elbow was ankylosed at 100 
degrees with a few degrees motion. Supination was 
limited. His wrist was fitted with a hyperextension 
splint. 

On June 4, 1918, as the elbow had not dis- 
charged for a year, an arthroplasty was advised. 
This was done July 24 at the Carney Hospital. The 
elbow was found ankylosed at 160 degrees. There 
was a musculospiral paralysis. 

Convalescence was uneventful. On August 10, the 
cast was removed. On August 10, motion without 
discomfort was possible from 70 to 120 degrees. He 
had a slight rise of temperature on the 13th but this 
quickly dropped. He was discharged from the 
hospital on August 17 to have dressings done by his 
family physician and to report from time to time to 
my office. 

September 7, he showed 15 degrees motion. On 
September 17, there was less motion. On October 24, 
motion had shut down to 8 degrees and a manipula- 
tion was advised. This was done on November 10, 
1 91 8, following which the elbow showed 10 degrees 
motion. 

On November 5, 1919, I- did a tendon trans- 
plantation for the relief of the musculospiral paralysis 
with excellent result. 

However, as motion in the elbow was restricted, 
further operative interference was advised. For this, 
the patient entered the Brooks Hospital where, on 
July 7, I removed the head of the radius and three- 
quarters of an inch of the humerus. 

He made a good recovery. On July 28, he had 
motion from 45 to 90 degrees. On August 25, he had 
motion from 75 to 135 degrees. On October 26, he 
showed motion from 40 degrees to 160 degrees. 

Case 25. F. D. In 1910, the right elbow became 
swollen and tender. At this time an open operation 
was done on the joint. Six months later, another 
operation was done, after which the elbow drained 
for 4 years and he lost the entire use of the arm. 

Physical examination showed marked atrophy of 
the muscles of the arm. There were numerus scars 



above and about the elbow. The elbow was anky- 
losed at 180 degrees. Finger and shoulder motions 
were normal. 

On August 10, 1918, by my usual method, I did an 
arthroplasty on his elbow. He made a good recovery 
and had a normal convalescence. Two weeks later, 
he was discharged to have daily dressings done by 
his family doctor. Motion at this time was from 80 
to 100 degrees without pain. 

He reported at my office on August 30. At this 
time, the wound was not quite healed. The elbow 
showed 30 degrees motion. Following this, he was 
seen about every 6 weeks. On October 18, the wound 
was found healed. Motion gradually increased. 

On December 9, 1919, he showed motion from 35 
to 145 degrees with full supination. The elbow was 
stable with no lateral motion. He has no pain, works 
as a telegraph operator and "lifts anything." 

Case 26. S. S. was first admitted to the Burbank 
Hospital, Fitchburg, December 5, 191 7, with a sub- 
acute neisserian infection. Five years previously the 
right knee had become swollen, and remained so for 
3 months. A month later, the right elbow became 
swollen and painful. At that time, she could bend 
the elbow but, as this caused pain, she did not do so. 
At the time of her admission, she could not bend the 
elbow nor lift the arm, and the elbow region was 
swollen and painful. The Wassermann test was 
positive. She remained in the hospital 38 days, 
receiving general treatment and was discharged 
relieved. 

She returned to the out-patient department, July 
1, 1 91 8. The arm was then put up in plaster from 
wrist to shoulder to remain on 2 months. She was 
told that her elbow would probably become stiff and 
would require an arthroplasty later. 

On January 9, 1919, the patient was advised to 
have an arthroplasty done as her elbow had become 
stiff. Following the operation on February 6 she had 
an uneventful recovery. The cast was removed in 2 
weeks, after which passive motion was begun. She 
was discharged March 18, 1919. 

When last seen, April 3, 191 9, she had a range of 
motion from 45 to 135 degrees. 

Case 27. N. B. was admitted to the House 
Mercy Hospital, Pittsfield, on March 4, 1919, for 
the relief of an ankylosis of 4 months' duration, the 
result of an infectious arthritis. There was marked 
atrophy of the left deltoid but no pain nor tenderness 
in the shoulder-joint and no limitation of motion. 
The left elbow was ankylosed at 150 degrees. She 
remained at this time in the hospital for a month 
under conservative treatment, then left the hospital 
unrelieved and was advised to return later for 
operative interference. 

On June 24, she re-entered the hospital. At this 
time, the elbow was ankylosed at 150 degrees. I did 
my usual arthroplasty and obtained a very good 
immediate result. The convalescence was uneventful 
but the patient did not co-operate in the after- 
treatment, spoiling what would otherwise have been 
an excellent result. 



MacAUSLAND: MOBILIZATION OF ELBOW — FREE FASCIA TRANSPLANT 23 



On September 16, following manipulation, she 
gained voluntary extension to 150 degrees. She 
returned to the outpatient department for massage 
and manipulation until December, 1919. At this 
time, she had motion from 75 to 120 degrees and a 
useful, stable arm. 

Case 28. W. M. had fractured his olecranon as 
the result of a fall. Following an open operation in 
which the olecranon was fastened in place with silver 
wire, the elbow gave him no further trouble until a 
year later following a second injury. When moving a 
heavy box, a second box had fallen and hit him 
on the elbow. Two weeks later, when he reported to 
the hospital, he was in great pain and showed a dis- 
charging sinus from which a piece of wire which was 
protruding was easily removed. Free drainage was 
established and later the arm was twice curetted. 
He was discharged March 21 after a tempestuous 
illness, to report to the out-patient department for 
dressings. In July, the wounds had healed and the 
patient was discharged to return in 6 months for an 
arthroplasty. 

This I did on July 9, 1919, and on his discharge 
from the hospital on September 4, he was able to 
flex and rotate his arm voluntarily. He is still under- 
going treatment and manipulation, baking, and 
massage. On October 18, 1919, he had voluntary 
motion from 158 to 105 degrees. On October 30, 
1920, he had voluntary motion from 60 degrees to 
135 degrees. 

BIBLIOGRAPHY 

1. Albarran. Cited by Hoffa, loc. cit. 

2. Albee. Orthopedic and Reconstruction Surgery. 

1918, p. 965. 

3. Allison and Brooks. Surg., Gynec. & Obst., 1913, 

xvii, 645. 

4. Ashhurst. Ann. Surg., 1915, lxii, 302. 

5. Baer. Am. J. Surg., 1918, xvi, 170. 

6. Bazy. Bull, et mem. soc. chir., Par., 1907, xxxii, 520. 

7. Berger. Bull, et mem. soc. chir., Par., 1901, xxix, 998. 

8. Brown. California St. J. M., 1916, xiv, 146. 

9. Ceccarelli. Riforma med., Napoli, 191 7, xxxiii, 

"73- 

10. Charput. (a) Bull, et mem. Soc. chir., Par., 191 2, 

xxxviii, 452; (b) 1915, xli, 1540. 

11. Cifuentes. Rev. de espec. med., Madrid, 1909, xii, 

73- ... 

12. Conrad. Dissertation, Kiel, 1912. 

13. Darling. Physician & Surg., 1913, xxxv, 71. 

14. Davis. Ann. Surg., 1914, lxi, 438; 1915, lxii, 378. 

15. Davis. Johns Hopkins Hosp. Bull., 191 1, Oct. 

16. Delangeniere. Bull, et mem. soc. chir., Par., 191 7, 

xliii, 2195. 

17. Delbet. Bull, et mem. soc. chir., Par., 1903, xxix, 

1172. 

18. Delbert. Gaz. med. d. Par., 191 2, lxxxiii, 117. 

19. Denk. Arch. f. klin. Chir., 1912, xcvii, 458. 

20. Dupuy. These de doct., Toulouse, 1903. 

21. Edmunds. Med. Press & Circ, 1912, xciv, 574. 

22. Exner. Wien. klin. Wchnschr., 1913, xxvi, 1821. 

23. Frisch, von. Wien. klin. Wchnschr., 1911, xxiv, 9222. 



24. Gilbert. Texas St. M. J., 1915, xxxi, 226. 

25. Graff. Deutsche med. Wchnschr., 1915, xli, 1502. 

26. Greiffenhagen. St. Petersb. med. Ztschr., 1913, 

xxxviii, 93. 

27. Harris. Texas St. J. M., 1913, xxix, 213. 

28. Helfereich. Verhandl. d. deutsch. Gesellsch. f. Chir., 

1894, xxiii, 504. 

29. Henderson. Am. J. Surg., 1918, svi, 30. 

30. Herzberg. Dissertation, Berlin, 1913. 

31. Hoffa. Ztschr. f. orthop. Chir., 1906, xvii, 1. 

32. Hofmann. Zentralbl. f. Chir., 1906, p. 16. 

33. Hohmeier and Magnus. Beitr. z. klin. Chir., 1914, 

xciv, 547. 

34. Hohmann. Berl. klin. Wchnschr., 1918, lx, 122. 

35. Huguier. (a) These de doct., Par., 1905; (b) Tribune 

med., Par., 1909, xli, 197. 

36. Kennedy. Tr. Roy. Acad. M. Ireland, 1915, xxxiii, 

223. 

37. Kerr. Surg., Gynec. & Obst., 1920, xxx, 518. 

38. MacAusland. J. Am. M. Ass., 1915, lxiv, 312. 

39. Mauclaire. Bull, med., Par., 1913, xxvii, 66. 

40. McCurdy. Pennsylvania M. J., 1914, xviii, 606. 

41. McKenna. J. Am. M. Ass., 1917, Ixix, 891. 

42. Moszkowicz. Berl. Ztschr. f. Chir., 1917, cv, 168. 

43. Murphy, (a) Tr. Am. Surg. Ass., 1904, xxii, 313; 

(b) Ann. Surg., 1913, lvii, 595; (c) Murphy's 
Clinics, 1914, iii, 523; (d) J. Am. M. Ass., 
1915, 851; (e) Murphy's Clinics, 1916, v, 641. 

44. Neff. Surg., Gynec. & Obst., 191 2, xv, 529. 

45. Nelaton. Bull, et mem. soc. chir., Par., 1902, 

xxviii, 687. 

46. Olivieri. Semanamed. , Buenos Aires, 1917, xxiv, 127. 

47. Osgood. Surg., Gynec. & Obst., 1913, xvii, 6. 

48. Owen. Ann. Surg., 1914, lix, 426. 

49. Payr. Deutsche Ztschr. f. Chir., 1914, cxxix, 341. 

50. Pereira. Brazil-med., Rio de Jan., 1906, xx, 361. 

51. Phemister and Miller. Surg., Gynec. & Obst., 

1918, xxvi, 406. 

52. Plummer. Surg., Gynec. & Obst., 1917, xxiv, 509. 

53. Pomponi. Gior. di med. mil., 1912, lx, 418. 

54. Pupovac. Wien. med. Wchnschr., 1914, xxvii, 151. 

55. Putti. Arch. d. ortop., Milano, 1913, xxx, 1. 

56. Quenu. (a) Bull. et. mem. Soc. chir., Par., 1902, 

xxviii, 724; (b) 1903, xxix, 112; (c) 1905, xxxi, 622. 

57. Rechet. VIII Cong, chir., Lyon, 1894. Arch. prov. 

Chir., 1896. 

58. Reiner. Deutsche Ztschr. f. Chir., 1910, xiv, 209. 

59. Roepke. Deutsche Chir. Kong., 1913, 116. 

60. RovsiNG. Tr. XI North. Surg. Cong., Gotenb., 1916. 

61. Ryerson. Surg. Clin. Chicago, 1917, 1, 197. 

62. Schanz. Muenchen. med. Wchnschr., 1904, 2228. 

63. Scudder. Boston M. & S. J., 1906, civ, 375; Ann. 

Surg., 1907, xiv, 297; 1908, xlvii, 711. 

64. Stein. Dissertation, Bonn, 1907. 

65. Steindler. J. Iowa St. M. Soc, 1916, vi, -284. 

66. Sumita. Arch. f. klin. Chir., 191 2, xcix, 755. 

67. Taylor. Pennsylvania M. J., 1912, xvi, 294. 

68. Thom. Deutsche Ztschr. f. Chir., 1910, cviii, 424. 

69. Thomson. Edinburg M. J., 1917, xix, 176. 

70. Tubby. Am. J. Orthop. Surg., 1915, xii, 381. 

71. Turner. Edinburgh M. J., 1914. xii, 433. 

72. Verneriel. Arch, de med., i860. 

73. Vulpius. Muenchen. med. Wchnschr., 1914, Mar. 17. 

74. Weglowski. Zentralbl. f. Chir., 1907, Apr. 27. 

75. Whitman. Ann. Surg., 1911, liv, 860; 1916, lxiii, 503. 

76. Wille. Norsk. Mag. f. Lagevidensk., 1911, ix, 40. 



.> u 



BACKACHE* 
W. Russell MacAusland, m.d. 

BOSTON, MASS. 

BACKACHE, because of its prevalence and its many etio- 
logical factors, is a subject of great interest to the entire 
medical profession, and any discussion that aids in its 
diagnosis and treatment is warranted. Like many medical 
problems it has been approached too frequently from the 
standpoint of the specialist. The orthopedist, urologist, 
gynecologist, psychiatrist, each has interpreted the cause of 
backache from his respective point of view. The orthopedist 
who is called upon to treat a large number of cases of back- 
ache should appreciate the variety of factors giving rise to 
the pain, and should realize that a wide knowledge of clinical 
conditions often is required for the solution of the problem. 
Backache, like arthritis, if approached with a narrow vision, 
not only may be treated without relief, but actual damage 
may be done to the patient by the removal of the so-called 
foci of infection. Undoubtedly, many laparotomies have 
been performed without relief because the pelvis alone was 
considered. On the other hand, many types of retentive 
apparatus have been employed in cases where the lesion was 
entirely or largely surgical. Therefore, in order that the 
proper treatment may be advised, a very thorough investiga- 
tion of all possible etiological factors should be made. The 
surgeon who does not use every means at his disposal, is 
bound to be unsuccessful in the treatment of a large pro- 
portion of his cases. On the other hand, it is my opinion 
that when great care is used, the treatment of backache is 
satisfactory. 

GENERAL SURGICAL, MEDICAL AND NEUROLOGICAL 
LESIONS, WITH REFERRED BACK PAIN 

Genito-urinary System. It has been demonstrated many 
times that the following conditions may frequently be 
associated with back pain. 

i. Floating kidney. 

2. Diseases of the kidney. 

3. Perinephritrc disease. 

4. Uretal conditions. 

5. Deformities and displacement of the pelvic organs. 

*This lecture was delivered on Nov. 9, 1923. 

275 

Reprinted from Practical Lectures, Delivered under the Auspices of The 

Medical Society of the County of Kings, Brooklyn, New York, 

[1923-1924 series], pages 275-288. Published by Paul 

B. Hoeber, Inc., New York. Copyright, 1925. 



276 W. RUSSELL MACAUSLAND 

In most cases it is possible either to prove or to rule out 
any of the above conditions. If present, they may be accepted 
as a definite factor, but it should be borne in mind that even 
when found, they may be of only little importance in the 
causation of back pain. 

Prostatitis and spermatocystitis have been considered 
definite causes by Baker, 2 Young, Geraghty and Stevens, 84 
and Smith. 45 Therefore, an examination of a man is not com- 
plete without determining the condition of the prostate 
gland and its adnexa. 

In women, malposition of the uterus has long been regard- 
ed as a potent cause of backache. Gradually, however, the 
old theory of pressure of the retroposed uterus on the nerves 
has been discarded and the more advanced gynecologists 
are admitting that pelvic disorders are not the direct causes of 
backache, but that they are usually concomitants. Graves, 17 
Cooley, 9 Brooke, 6 Reynolds and Lovett, 38 Sever 44 and many 
others emphasize the association between pelvic conditions 
and back pain. Phaneuf 35 seems to me to have expressed the 
most reasonable view on the subject, namely, that the ordi- 
nary deformities of the uterus, such as retroversion, ante- 
flexion, etc., are not causes, but that the heavy, boggy, 
mildly infected uterus sinking low in the pelvis, may defi- 
nitely cause back pain by pulling on the nerve structures. 
A heavy, subinvoluted uterus represents the type of lesion 
that may give rise to back pain. 

Cancer in the pelvis might also bring about a similar 
condition, although in such cases there is the possibility of 
the involvement of the nerve sheaths, and even of the nerves 
themselves. 

Backache associated with menstruation seems to me to 
represent a combination of the factors : nerves, fatigue, and 
the laxity or susceptibility of the pelvic joint to strain. 

Abdominal Conditions. Abdominal conditions associated 
with back pain are very numerous, particularly those repre- 
senting infections, such as the infected gall-bladder, appen- 
dix, etc. The dragging of a large scrotal or abdominal hernia 
may also be accompanied by back pain. New growths 
should, of course, be considered separately. Metastases of 
the spine take place with such frequency that actual local 
disease in the spine must be considered in every case, and 
such a condition will be treated under lesions of the spine. 

Neurological Lesions. The neurologist finds many condi- 
tions giving rise to back pain. Cases that present definite 
diagnostic signs of irritation or degeneration in the central 



BACKACHE 277 

or peripheral nervous system should come directly under his 
care. Those which represent neurasthenic, functional or 
hysterical conditions, should be examined with great care, 
as frequently such cases are malingering. In my opinion 
such a diagnosis is rarely justified. 

Focal Infections. In regard to focal infections as a cause of 
backache, I believe they act always through intermediate 
conditions, the most common of which is arthritic infection. 
Focal infections, therefore, may be considered under the 
treatment of arthritis, the well-known cause of back pain. 
I do not wish to belittle the importance of focal infections, 
but I do wish to emphasize the need of giving attention to 
the intermediate condition that the infection produces, as 
well as to the eradication of the focus itself. 

BONE AND JOINT CONDITIONS WITH REFERRED BACK PAIN 

Static and Postural Lesions. The term "static" implies an 
alteration in the relation that the different parts of the 
body bear to each other. The human body works always in 
fixed lines and planes, with certain variations and limits of 
motion. Checks to the motion of the back are ligaments 
about the lower end of the spine which are particularly 
strong and relax only under extreme stress and strain. If 
abnormal positions are maintained for a sufficient length of 
time, these ligaments may be constantly strained, or the 
spine or other structures may be affected, and static back- 
ache result. Constant postural and static strain may affect 
the back to such an extent as to cause actual arthritic 
changes in addition to backache (Fig. 95). If a chronic condi- 
tion persists, the postural defect may progress to actual 
displacement of the last lumbar vertebra. This may be 
demonstrated by lateral x-rays of the spine (Fig. 96). The 
displacement causes a pinch in the posterior vertebral body 
and is responsible for much of the pain, arthritic changes 
and referred leg pain occurring in this type of case. 

Postural changes causing backache may be classified as 
flat back, lordosis, round shoulders, faulty position in the 
back itself, or they may be secondary from abdominal 
ptosis or overweight. 

The static defects are chiefly due to flat feet, knock-knees, 
short leg, congenital hip and scoliosis. 

Many of the postural defects develop from assuming a 
definite position in occupation or from performing constant 
rhythmic movements involving the spine. 

A great deal has been written upon the recognition of this 



2 7 8 



W. RUSSELL MACAUSLAND 



static element. In 1910, Reynolds and Lovett 38 propounded 
the "static" theory that backache is due to the forward dis- 
placement of the center of gravity of the body and that the 
undue strain on the posterior muscles and ligaments causes 
the pain. Goldthwait and Osgood, 16 Brooke, 6 Dameshek, 11 
Kuth, 24 Woodbury, 47 Ogilvy, 30 Graves, 17 Marshall, 28 Kos- 
mak, 22 O'Ferrall, 29 have written upon the importance of this 
static disturbance. 




Fig. 95. Showing arthritic changes of the spine. 
LOCAL LESIONS IN BONE, MUSCLES AND LIGAMENTS 

Injections. In my experience, arthritis of the spine has 
proved to be the most frequent cause of back-pain condi- 
tions. Definite pathological symptoms are found, which, for 
the most part, are amenable to proper treatment. Arthritis 
of the spine is practically universal and may be demonstrated 
in the spine of almost every person over forty years of age. 
Arthritis of the spine, as of other joints, may be of various 
types — hypertrophic, osteoarthritic, etc. (Figs. 95 and 97). 
Infection from a distant foci passing through the blood may 
localize in a back strained from postural, static or traumatic 
conditions. 



BACKACHE 



279 



Limitation of motion, so characteristic of joint disease, 
is associated with this arthritic process. Muscle spasm, pro- 
tective in nature, acting with the usual checks of motion, 
gives rise to an abnormal limitation. 

Cancer, tuberculosis, syphilis and other diseases of the bone 
may also cause definite pain. 

Traumatic. Injuries may result in strain or fractures. 





A B 

Figs. 96 A and B. Showing forward displacement of the fifth lumbar vertebra. 

The structures involved in the traumatic processes are the 
sacroiliac joints, the lumbar spine and the lumbosacral 
junction. 

Strain. A change from the normal position produces a 
strain on the ligaments and muscles. A simple muscular or 
ligamentous strain is a common industrial complaint. The 
strain may be acute or chronic. Faulty posture may cause an 
acute strain. A dorsal position on a table maintained for a 
long period during operation, may produce an acute strain 
of the lumbar ligaments. Chronic strain occurs in cases of 
congenital dislocation of the hip, short leg and static defects 
in the lower back. The chronic types may develop into low- 
grade arthritic processes. Therefore, in making an exami- 
nation, these static, traumatic and infectious processes 
should be kept in mind. 

There has been much controversy in regard to the 
dislocation, relaxation and subluxation of the sacroiliac 
joints. As early as 1870, relaxation and subluxation were 
associated with pregnancy. Since 1905, when Goldthwait and 
Osgood 10 explained their theory in regard to the dislocation 
of the sacroiliac joints, there has been considerable dis- 



280 



W. RUSSELL MACAUSLAND 



cussion. Some have agreed that slight dislocations are possi- 
ble, others have demanded pathologic and radiographic 
proofs. 

More recently it is being recognized that these displace- 
ments have been overestimated. Actually the joints between 
the sacrum and the ilium are the most perfectly protected in 
the whole human body. Four major ligaments and several 
minor ones give protection. In my entire practice I have 
never been able to demonstrate, by clinical examination or by 
x-rays, the presence of a dislocation of the joint, except in 
cases of severe traumatism, such as occur in automobile or 




Fig. 97. Showing hypertrophic scoliosis. 

railroad accidents. Relaxation and subluxation of the sacro- 
iliac joints are infrequent, occurring only during the course 
of pregnancy, and they tighten up very early after delivery. 
It is of significance that during pregnancy, when these joints 
are relaxed, symptoms of back pain are only rarely present. 
In cases of overweight, postural conditions cause strain in 
these relaxed joints, and increase the symptoms and 
disability. 

Many of the lesions supposedly of sacroiliac origin, are 
actually lumbosacral. This feature is often brought out in a 
routine examination of the back in cases of postural defects, 
in which there is an actual forward displacement of the fifth 
lumbar vertebra on the sacrum (Fig. 96). 

The acute attacks that are frequently relieved by 
osteopathic treatment are simply muscle cramps following 



BACKACHE 28l 

ligamentous strain. Such a condition is seen in cramps in the 
calves of the legs following overexercise and overuse. 

Frequently, heat, massage and manipulation will increase 
the circulation and give relief. 

Fractures. Infrequently, fractures occur in the region of 
the sacroiliac joints. In the lumbar region a crush fracture 
occurs most commonly at the junction of the vertebrae. 
Crush fractures of the articular processes and fractures of 
transverse process are uncommon. 

Fracture, or lateral displacements of the coccyx, usually 
cause localized pain. In chronic cases it is largely postural in 




Fig. 98. Showing spina bifida. 

origin, with neurasthenic conditions superimposed. In trau- 
matic cases in which a definite fracture or displacement of the 
tip of the coccyx is demonstrated by digital examination and 
the x-ray, the condition is often relieved by the removal of 
the fractured or displaced tip. In some cases, however, pain 
persists after the removal. Surgery in this type of case is not 
to be advised. 

Congenital Abnormalities. Congenital abnormalities in 
general should not be considered an actual cause of back pain, 
but merely a predisposing factor. These abnormalities in 
themselves rarely give rise to symptoms, without some 
extraneous cause, which is most frequently static, postural, 
traumatic or infectious. 

Not infrequently, spina bifida or failure of the closure of the 



282 



W. RUSSELL MACAUSLAND 



posterior arches, from which the patient has no symptoms, 
is found in a routine examination of the spine (Fig. 98). 

Varying degrees of sacrilization, from a mere broadening 
or lengthening of the transverse process of the fifth lumbar 
vertebra to an actual antler wing on one or both sides, may 
be found. This sacrilization is undoubtedly of congenital 
origin (Figs. 99 and 100). Ludloff 27 and Scheede 43 made the 
first careful study of the appearance of the structure in x-rays. 
It varies in size and in position with reference to the level of 
the iliacs. It may be increased in length and width and flat- 
tened out into broad, bilobed structures, tipping upward and 
backward. It may develop to conform with the shape of the 
adjacent iliacs. O'Reilly 31 studied the x-rays of 300 patients 




Fig. 99. Showing long transverse process of the fifth lumbar vertebra. 



suffering from backache. He found three general types of 
transverse processes of the fifth lumbar vertebra, the straight 
type, the fan-shaped type and the bulbous, the last being 
most common. It was his opinion that occupation played an 
important part in the development of these variations. 
Abnormalities of the last lumbar vertebra will cause no symp- 
toms unless aggravated by static, postural, traumatic or 
infectious lesions. In such cases it is more difficult to relieve 
the condition. In 3 cases I have found it necessary to resort to 
surgical interference. 

If the transverse process is so long that it comes in close 
contact with the iliac crest without actually being con- 



BACKACHE 



283 



nected by a bony bridge, a bursa may develop. In some cases 
pressure may result in the fusion of the tip of the process with 
the ilium. 

Only a few cases of excision have been reported in liter- 
ature. Some surgeons have tended to discourage the oper- 
ation, as they claim damage may be done to the nerve 
structures coming out above or below the transverse process. 
Others believe with Epstein 13 that the postoperative treat- 
ment, not the excision itself, relieves the condition. 

Blanchard and Parker 5 reported the first successful case 
of excision in 19 15. Rugh, 42 Adams, 1 Lavieri 25 and Knox 23 




Fig. 100. Showing sacrilization of the transverse process of the fifth lumbar 

vertebra. 



have each reported a successful case since that time 
reported operating on 3 other cases on which it 



Knox 
was too 



early to report, but which presented good prospects. 

Pathology 

The pathology of these bone and joint conditions occurring 
in the spine does not differ from the pathology of bone and 
joint lesions elsewhere. The intervertebral discs may be 
regarded as joints. They become thinned and absorbed. 
The edges of the adjoining bone become hardened and form 
spurs. 

Swelling about a badly strained, infected or diseased 
articular process causes impingement on the nerve which 



284 W. RUSSELL MACAUSLAND 

emerges from the spinal canal through a small foramen. 
This foramen is practically bony in outline and confines the 
nerve in its bony canal. Pressure, therefore, has an effect 
out of all proportion to similar pressure elsewhere on nerves. 

The x-ray pathology is easy to interpret in advanced 
cases, but in cases in the early stages, there is an extraordi- 
nary lack of appreciation of the slight changes. 

The swelling of tissues along the spine tends to give a 
"washed-out" appearance to the bone and joint shadows. 

There is also slight thinning of the intervertebral discs, and 
the edges of the vertebrae become slightly penciled, due to 
atrophy. 

There may be a slight asymmetry of one vertebra upon 
another, showing that one joint has given away somewhat 
more than its fellow on the opposite side. 

All the above signs seem to be frequently overlooked, and 
yet each is of importance. 

Diagnosis 

The diagnosis of the so-called orthopedic causes of back 
pain is based upon the same signs as appear in the examina- 
tion of any joint. 

1. Deformity. 

2. Limitation of motion (asymmetrical or symmetrical). 

3. Muscle spasm. 

4. Definite pain or soreness on extremes of motion (when 
motion is forced with sudden jerk). 

5. Local tenderness. 

6. Local heat. 

7. Local swelling. 

The three latter factors may be observed only when great 
care is used in the examination of the lower lumbar and 
sacroiliac joints. Anteroposterior and lateral radiograms 
should be taken in erect and recumbent positions. In general, 
a probable orthopedic cause for back pain may be certain in 
any patient who presents limitation of motion of the spine, 
and may be considered very probable in all cases in which 
this limitation of motion is accompanied by muscle spasm 
and local tenderness and pain. 

Treatment 

Bed. The bed is one of the first factors to consider in the 
treatment of backache. Most beds sag, whether a person is 
stout or thin. This sag alone may cause back pain and if 
continued, produce chronic back strain. This condition 



BACKACHE 285 

should be corrected so that the back is held in proper position 
during rest. The most convenient method is to place a frac- 
ture board between the spring and the mattress, placing a 
blanket crosswise on the board so that it will come under 
the upper lumbar spine. 

All static defects, such as flat-foot, knock-knee, round 
shoulders and abdominal ptosis should be eliminated by 
mechanotherapy, correction of faulty habits, and exercises. 
If deformity is corrected and the proper habit of standing, 
sitting and lying is formed, no further treatment will be 
necessary. 

In the infectious type of case, all existing foci of infection 
should be eliminated. The patient must improve his general 
condition by fresh air, sun exposures and good habits. 
Supportive treatment may be necessary, depending entirely 
upon the severity and chronicity of the process. In the acute 
stages, bed treatment is most important. As soon as the symp- 
toms have subsided and the deformity has been corrected, 
some type of retentive or supportive apparatus is absolutely 
necessary in order to hold the correction and relieve the 
patient of further strain. This support may be removed when 
the surgeon judges that recurrence is impossible. The 
apparatus should be removed as soon as possible, and baking, 
massage and all other means employed to stimulte circula- 
tion and increase the musculature and the ligamentous tone. 

If these infectious elements and all static and postural 
defects are eliminated, most of the back trouble, if of 
orthopedic origin, will be relieved. 

In cases of back pain due to pelvic lesions alone, or 
associated with true back lesions, the pelvic, intra-abdominal 
or general medical problems must be treated hand in hand. 

Conclusions 

The most constant cause of backache from an orthopedic 
standpoint is low-grade arthritis. An infectious element, 
usually present, associated with a chronic strain, produces 
many of the cases of arthritis that appear in middle life. 

I am certain that static and postural elements enter 
into almost all low back pain of orthopedic origin. 

Congenital abnormalities, in themselves, are not a cause 
of back pain, but they may be a potential danger, making 
differential diagnosis and treatment more difficult. 

BIBLIOGRAPHY 

1. Adams. In discussion of Blanchard and Parker's paper. Am. J. Orthop. 
Surg., Phila., 1915-16, xiii, 250. 



286 W. RUSSELL MACAUSLAND 

2. Baker. Am. J. Orthop. Surg., 1917, xv, 819. 

3. Behrend. TV. York M. J., 1920, cxii, 409. 

4. Bevan. Tr. Am. Urol. Ass., iii, 397. 

5. Blanchard and Parker. Am. J. Orthop. Surg., 1915-16, xiii, 250. 

6. Brooke. Hahneman. Month., Phila., 1917, Iii, 531. 

7. Bullard. TV. York M. J., 1921, cxiii, 142. 

8. Byran. Surg., Gynec. & Obst., Feb., 1911. 

9. Cooley. Illinois M. J., Chicago, 1920, xxxvii, 195. 

10. Crossen. Diseases of Women, St. Louis, 1922, p. 195. 

11. Dameshek. Boston M. €f S. J., 1922, clxxxvii, 830. 

12. Davis. Am. J. Orthop. Surg., Bost., 1917, xv, 803. 

13. Epstein. Med. Rec, 1921, xcix, 734. 

14. Fassett. Am. J. Orthop. Surg., Bost., 191 7, xv, 826. 

15. Gellhorn. Gynecological and Obstetrical Monographs. New York- 

London, 1923. 

16. Goldthwait and Osgood. Boston M. & S. J., 1905, Nos. 21 and 22. 

17. Graves. Am. J. Orthop. Surg., Bost., 1917, xv, 807. 

18. Henneberg. Gynecologie et Obstetrique, viii, No. 2, 1922. 

19. Henniger. Am. J. Orthop. Surg., 1917, xv, 814. 

20. Hunner. TV. York M. J., 19 16, civ, 5. 

21. Hutchins. J. A. M. A., Sept. 23, 1916, Ixvii, No. 13. 

22. Kosmak. TV. York M. J., 191 5, cii, 589. 

23. Knox. Texas State J. M., Fort Worth, 1921-22, xvii, 355. 

24. Kuth. J. Bone & Joint Surg., Bost., 1922, iv, 357. 

25. Lavieri. Illinois M. J., Chicago, 1919, xxxvi, 197. 

26. Lynch. Am. J. Obst. & Gynec., iv, No. 4, Oct., 1922. 

27. Ludloff. Fortschr. a. d. Geb. d. Rontgenstrablen., ix and xi. 

28. Marshall. Boston M. & S. J., 19 16, clxxiv, 591. 

29. O'Ferrall. J. Bone & Joint Surg., Bost., 1922, iv, 384. 

30. Ogilvy. TV. York M. J., 1914, c, 1107. 

31. O'Reilly. J. Orthop. Surg., 1921, iii, 171. 

32. Osgood. Tr. Am. Ass. Genito-Urin. Surg., ii, 283. 

33. Paul, W. E. Boston. Views submitted personally. 

34. Peacock. Northwest Med., Seattle, 1922, xxi, 12. 

35. Phaneuf, L. E. Boston. Views submitted personally. 

36. Platt. Med. Chron., Manchester, 1914-15, Ix, 80. 

37. Proust. Gynecologie et Obstetrique, viii, No. 2, 1922. 

38. Reynolds and Lovett. J. A. M. A., Mar. 26, 1910, Iiv, No. 13. 

39. Roberts. N. York State J. M., N. Y., 1919, xix, 18. 

40. Rosenbeck. N. York M. J., 1921, cxiii, 138. 

41. Rubin. Gynecological and Obstetrical Monographs. New York-London, 

1923. 

42. Rugh. In discussion of Blanchard and Parker's paper. Am. J. Orthop. 

Surg., Phila., 1915-16, xiii, 260. 

43. Scheede. Fortschr. a. d. Geb. d. Rontgenstrablen, xvii, 255. 

44. Sever. Boston M. & S. J., 1918, clxxviii, 323. 

45. Smith, George Gilbert. Boston. Views submitted personally. 

46. Van Zwaluwenburg. J. Mich. M. Soc, Grand Rapids, 1916, xv, 428. 

47. Woodbury. TV. York State J. M., N. Y., 1919, xix, 18. 

48. Young, Geraghty and Stevens. Johns Hopkins Hosp. Rep., Bait., 

1906, xiii, 271. 



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